CARIN Consumer Directed Payer Data Exchange
0.4.0 - STU1

CARIN Consumer Directed Payer Data Exchange - Local Development build (v0.4.0). See the Directory of published versions

Resource Profile: CARINBBExplanationOfBenefitInpatientFacility

The profile is used for Explanation of Benefits (EOBs) based on claims submitted by clinics, hospitals, skilled nursing facilities and other institutions for inpatient services, which may include the use of equipment and supplies, laboratory services, radiology services and other charges. Inpatient claims are submitted for services rendered at a facility as part of an overnight stay. The claims data is based on the institutional claim format UB-04, submission standards adopted by the Department of Health and Human Services as form CMS-1450.

The official URL for this profile is:

http://hl7.org/fhir/us/carin-bb/StructureDefinition/CARIN-BB-ExplanationOfBenefit-Inpatient-Facility

Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work.

This structure is derived from CARINBBExplanationOfBenefit

Summary

Mandatory: 5 elements (8 nested mandatory elements)
Must-Support: 24 elements

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element ExplanationOfBenefit.supportingInfo is sliced based on the value of pattern:category
  • The element ExplanationOfBenefit.procedure.procedure[x] is sliced based on the value of type:$this
  • The element ExplanationOfBenefit.item.adjudication is sliced based on the value of pattern:$this (Closed)
  • The element ExplanationOfBenefit.adjudication is sliced based on the value of value:category (Closed)
  • The element ExplanationOfBenefit.total is sliced based on the value of value:category

This structure is derived from CARINBBExplanationOfBenefit

NameFlagsCard.TypeDescription & Constraintsdoco
.. ExplanationOfBenefit 0..*CARINBBExplanationOfBenefitExplanation of Benefit resource
... identifier S1..*IdentifierClaim identifier for a claim. (35 )
... status S1..1code (140 )
... type 1..1CodeableConceptSpecifies the type of claim. (e.g., inpatient insitutional, outpatient institutional, physician, etc.). (16 )
Required Pattern: At least the following
.... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
..... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: institutional
.... coding S1..1CodingCode defined by a terminology system
... billablePeriod 0..1PeriodIdentifies the date the patient was admitted/discharged for facility care (18,19 )
... provider 1..1Reference(CARIN BB Organization)The National Provider Identifier assigned to the Billing Provider. (94 )
... related 0..*BackboneElementReplaced or Merged claim number (112 )
... payee
.... type 1..1CodeableConceptIdentifies recipient of benefits payable; i.e., provider or subscriber (120 )
.... party 1..1Reference(CARIN BB Organization | CARIN BB Patient | CARIN BB Practitioner)Recipient reference (121 )
... careTeam I0..*BackboneElementCare Team members
EOB-inst-careTeam-practitioner: Institutional EOB: Careteam roles refer to a practitioner
EOB-inst-careTeam-organization: Institutional EOB: Careteam roles refer to a practitioner
.... provider 1..1Reference(CARIN BB Organization | CARIN BB Practitioner)The NPI of the referring physician. (99 )
.... role 1..1CodeableConceptFunction within the team
Binding: CARINBB Institutional Claim Care Team Roles (required)
... supportingInfo 0..*(Slice Definition)Supporting information
Slice: Unordered, Open by pattern:category
.... supportingInfo:All Slices Content/Rules for all slices
..... code 0..1CodeableConceptPatient’s status as of the discharge date for a facility stay. Information located on UB04 (Form Locator 17). (117 )
.... supportingInfo:billingnetworkcontractingstatus 0..1BackboneElementIndicates that the Billing Provider has a contract with the Plan (regardless of the network) as of the effective date of service or admission. (101 )
..... category 1..1CodeableConceptClassification of the supplied information
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/ClaimInformationCategoryCS
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: billingnetworkcontractingstatus
..... code 1..1CodeableConceptType of information
Binding: Provider Provider Contracting Status (required)
.... supportingInfo:attendingnetworkcontractingstatus 0..1BackboneElementIndicates the network status of the attending physician (101 )
..... category 1..1CodeableConceptClassification of the supplied information
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/ClaimInformationCategoryCS
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: attendingnetworkcontractingstatus
..... code 1..1CodeableConceptType of information
Binding: Provider Provider Contracting Status (required)
.... supportingInfo:referringnetworkcontractingstatus 0..1BackboneElementIndicates the network status of the referring physician (101 )
..... category 1..1CodeableConceptClassification of the supplied information
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/ClaimInformationCategoryCS
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: referringnetworkcontractingstatus
..... code 1..1CodeableConceptType of information
Binding: Provider Provider Contracting Status (required)
.... supportingInfo:supervisingnetworkcontractingstatus 0..1BackboneElementSupporting information
..... category 1..1CodeableConceptClassification of the supplied information
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/ClaimInformationCategoryCS
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: supervisingnetworkcontractingstatus
..... code 1..1CodeableConceptType of information
Binding: Provider Provider Contracting Status (required)
.... supportingInfo:clmrecvddate 0..1BackboneElementThe date the claim was received by the payer (88 )
..... category 1..1CodeableConceptClassification of the supplied information
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/ClaimInformationCategoryCS
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: clmrecvddate
..... timing[x] 1..1dateWhen it occurred
.... supportingInfo:typeofbill 0..1BackboneElementUB04 (Form Locator 4) type of bill code provides specific information for payer purposes. The first digit of the three-digit number denotes the type of facility, the second digit classifies the type of care being billed, and the third digit identifies the frequency of the bill for a specific course of treatment or inpatient confinement. (17 )
..... category 1..1CodeableConceptClassification of the supplied information
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/ClaimInformationCategoryCS
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: typeofbill
..... code 0..1CodeableConceptType of information
Binding: nubc-type-of-bill (required)
.... supportingInfo:pointoforigin 0..1BackboneElementIdentifies the place where the patient was identified as needing admission to a facility. This is a two position code mapped from the standard values for the UB-04 Source of Admission code (FL-15). (13 )
..... category 1..1CodeableConceptClassification of the supplied information
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/ClaimInformationCategoryCS
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: admsrc
..... code 0..1CodeableConceptType of information
Binding: nubc-admission-source (required)
.... supportingInfo:admtype 0..1BackboneElementClaim Priority (Type) of Admission or Visit
..... category 1..1CodeableConceptClassification of the supplied information
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/ClaimInformationCategoryCS
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: admtype
..... code 0..1CodeableConceptType of information
Binding: NUBC Priority of Admission (required)
.... supportingInfo:discharge-status 0..1BackboneElementDischarge Status
..... category 1..1CodeableConceptClassification of the supplied information
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/ClaimInformationCategoryCS
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: discharge-status
..... code 0..1CodeableConceptType of information
Binding: NUBC Patient Discharge Status (required)
.... supportingInfo:drg 0..1BackboneElementClaim diagnosis related group (DRG)
..... category 1..1CodeableConceptClassification of the supplied information
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/ClaimInformationCategoryCS
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: drg
..... code 0..1CodeableConceptType of information
Binding: CMS-DRG (required)
.... supportingInfo:onadmissiontype 0..1BackboneElementOn Admission Type
..... code 0..1CodeableConceptType of information
Binding: Payer Diagnosis Present On Admission Diagnosis Type (required)
... diagnosis S1..*BackboneElementThis is the reason given by the patient for visiting the doctor or practitioner. It is not the doctor's or practitioner's diagnosis. Patient Reason for Visit Codes can be any ICD-10diagnosis and may or may not be a repeat of an ICD-10 Principal or Secondary diagnosis field. (31 )
.... diagnosis[x] S1..1CodeableConceptA plain text representation of the diagnosis (145 )
Binding: ICD-10-CM Diagnosis Codes (required)
.... type S1..1CodeableConceptTiming or nature of the diagnosis
Binding: Diagnosis Type -- Inpatient Facility (required)
.... onAdmission S0..1CodeableConceptUsed to capture whether a diagnosis was present at time of a patient's admission. This is used to group diagnoses into the proper DRG for all claims involving inpatient admissions to general acute care facilities. (28 )
Binding: NUBC Present On Admission (required)
... procedure 0..*BackboneElementPrincipal medical procedure a patient received during inpatient stay. Coding methods for this field is International Classification of Diseases Surgical Procedures (ICD-10). (24 )
.... procedure[x] S1..1(Slice Definition)Specific clinical procedure
Slice: Unordered, Open by type:$this
.... procedureCodeableConcept 0..1CodeableConceptSpecific clinical procedure
Binding: ICD-10-PCS (required)
... insurance 1..*BackboneElementIdentifies the primary payer. For use only on secondary claims. (141 )
.... coverage 1..1Reference(CARIN BB Coverage)Unique identifier for a member assigned by the Payer. If members receive ID cards, that is the identifier that should be provided. (1 )
... item
.... sequence S1..1positiveIntLine identification number that represents the number assigned in a source system for identification and processing. (36 )
.... revenue S0..1CodeableConceptCode used on the UB-04 (Form Locator 42) to identify a specific accommodation, ancillary service, or billing calculation related to the service being billed (86 )
Binding: nubc-service-line-revenue (required)
.... productOrService S1..1CodeableConceptMedical procedure a patient received from a health care provider. Current coding methods include: CPT-4 and HCFA Common Procedure Coding System Level II - (HCPCSII). (40 )
Binding: AMA CPT and CMS HCPCS Procedure Codes (required)
.... modifier S0..*CodeableConceptModifier(s) for the procedure represented on this line. Identifies special circumstances related to the performance of the service. (41 )
Binding: AMA CPT and CMS HCPCS Modifier Codes (required)
.... quantity S0..1SimpleQuantityThe quantity of units, times, days, visits, services, or treatments for the service described by the HCPCS code, revenue code or procedure code, submitted by the provider. (42 )
.... adjudication 0..*(Slice Definition)The quantity of units, times, days, visits, services, or treatments allowed for the service described by the HCPCS code, revenue code or procedure code, submitted by the provider. (149 )
Slice: Unordered, Closed by pattern:$this
..... adjudication:adjudicationamounttype 0..*BackboneElementAmounts
...... category 1..1CodeableConceptType of adjudication information
Binding: Adjudication CARINBB Value Codes (required)
...... amount S0..1MoneyMonetary amount
..... adjudication:denialreason 0..1BackboneElementDenial Reason
...... category 1..1CodeableConceptType of adjudication information
Required Pattern: At least the following
....... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
........ system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/ClaimAdjudicationCategoryCS
........ code1..1codeSymbol in syntax defined by the system
Fixed Value: denialreason
...... reason 1..1CodeableConceptExplanation of adjudication outcome
Binding: Adjudication Denial Reason (required)
..... adjudication:allowedunits 0..1BackboneElementAllowed number of units
...... category 1..1CodeableConceptType of adjudication information
Required Pattern: At least the following
....... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
........ system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/ClaimAdjudicationCategoryCS
........ code1..1codeSymbol in syntax defined by the system
Fixed Value: allowedunits
... adjudication 0..*(Slice Definition)Header-level adjudication
Slice: Unordered, Closed by value:category
.... adjudication:All Slices Content/Rules for all slices
..... category S1..1CodeableConceptIndicates the in network or out of network payment status of the claim. (142 )
.... adjudication:adjudicationamounttype 0..*BackboneElementAmounts
..... category 1..1CodeableConceptType of adjudication information
Binding: Adjudication CARINBB Value Codes (required)
..... amount 1..1MoneyMonetary amount
.... adjudication:denialreason 0..1BackboneElementDenial Reason
..... category 1..1CodeableConceptType of adjudication information
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/ClaimAdjudicationCategoryCS
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: denialreason
..... reason 1..1CodeableConceptExplanation of adjudication outcome
Binding: Adjudication Denial Reason (required)
... total 1..*(Slice Definition)Adjudication totals
Slice: Unordered, Open by value:category
.... total:All Slices Content/Rules for all slices
..... category S1..1CodeableConceptType of adjudication information
..... amount S1..1MoneyTotal amount for each category (i.e., submitted, allowed, etc.) (148 )
.... total:adjudicationamounttype S0..*BackboneElementAmounts
..... category 1..1CodeableConceptType of adjudication information
Binding: Adjudication CARINBB Value Codes (required)
..... amount S1..1MoneyFinancial total for the category
.... total:inoutnetwork S1..1BackboneElementBenefit Payment Status
..... category 1..1CodeableConceptType of adjudication information
Binding: Benefit Payment Status (required)
..... amount S1..1MoneyFinancial total for the category
... payment
.... type S0..1CodeableConceptIndicates whether the claim was paid or denied. (91 )
.... adjustmentReason S0..1CodeableConceptReason codes used to interpret the Non-Covered Amount (92 )
.... date S0..1dateThe date the claim was paid. (107 )

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. ExplanationOfBenefit I0..*CARINBBExplanationOfBenefitExplanation of Benefit resource
... id Σ0..1stringLogical id of this artifact
... meta ΣI0..1MetaMetadata about the resource
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... versionId ΣI0..1idVersion specific identifier
.... lastUpdated SΣI1..1instantWhen the resource version last changed
.... source ΣI0..1uriIdentifies where the resource comes from
.... profile SΣI1..*canonical(StructureDefinition)Profiles this resource claims to conform to
.... security ΣI0..*CodingSecurity Labels applied to this resource
Binding: All Security Labels (extensible)
.... tag ΣI0..*CodingTags applied to this resource
Binding: CommonTags (example)
... implicitRules ?!ΣI0..1uriA set of rules under which this content was created
... language I0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred)
Max Binding: AllLanguages
... text I0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension I0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!I0..*ExtensionExtensions that cannot be ignored
... identifier SI1..*(Slice Definition)Claim identifier for a claim. (35 )
Slice: Unordered, Open by pattern:$this
.... identifier:claimnumber SI1..1IdentifierClaim Number

Required Pattern: At least the following
..... id0..1stringUnique id for inter-element referencing
..... extension0..*ExtensionAdditional content defined by implementations
..... use0..1codeusual | official | temp | secondary | old (If known)
..... type1..1CodeableConceptDescription of identifier
Fixed Value: (complex)
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/IdentifierTypeCS
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: cn
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... system0..1uriThe namespace for the identifier value
..... value0..1stringThe value that is unique
..... period0..1PeriodTime period when id is/was valid for use
..... assigner0..1Reference(Organization)Organization that issued id (may be just text)
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... use ?!ΣI0..1codeusual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required)
..... type ΣI0..1CodeableConceptDescription of identifier
Binding: Identifier Type Codes (extensible)
..... system ΣI0..1uriThe namespace for the identifier value
Example General: http://www.acme.com/identifiers/patient
..... value SΣI1..1stringThe value that is unique
Example General: 123456
..... period ΣI0..1PeriodTime period when id is/was valid for use
..... assigner ΣI0..1Reference(Organization)Organization that issued id (may be just text)
... status ?!SΣI1..1code (140 )
Binding: ExplanationOfBenefitStatus (required)
... type SΣI1..1CodeableConceptSpecifies the type of claim. (e.g., inpatient insitutional, outpatient institutional, physician, etc.). (16 )
Binding: ClaimTypeCodes (required)
Required Pattern: At least the following
.... id0..1stringUnique id for inter-element referencing
.... extension0..*ExtensionAdditional content defined by implementations
.... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
..... id0..1stringUnique id for inter-element referencing
..... extension0..*ExtensionAdditional content defined by implementations
..... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type
..... version0..1stringVersion of the system - if relevant
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: institutional
..... display0..1stringRepresentation defined by the system
..... userSelected0..1booleanIf this coding was chosen directly by the user
.... text0..1stringPlain text representation of the concept
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... coding SΣI1..1CodingCode defined by a terminology system
.... text ΣI0..1stringPlain text representation of the concept
... subType I0..1CodeableConceptMore granular claim type
Binding: ExampleClaimSubTypeCodes (example)
... use ΣI1..1codeclaim | preauthorization | predetermination
Binding: Use (required)
Required Pattern: claim
... patient SΣI1..1Reference(CARIN BB Patient)Provider submitted information that can be included on the claim (110 )
... billablePeriod SΣI0..1PeriodIdentifies the date the patient was admitted/discharged for facility care (18,19 )
... created ΣI1..1dateTimeResponse creation date
... enterer I0..1Reference(Practitioner | PractitionerRole)Author of the claim
... insurer SΣI1..1Reference(CARIN BB Organization)Party responsible for reimbursement
... provider SΣI1..1Reference(CARIN BB Organization)The National Provider Identifier assigned to the Billing Provider. (94 )
... priority I0..1CodeableConceptDesired processing urgency
Binding: http://terminology.hl7.org/CodeSystem/processpriority (example)
... fundsReserveRequested I0..1CodeableConceptFor whom to reserve funds
Binding: Funds Reservation Codes (example)
... fundsReserve I0..1CodeableConceptFunds reserved status
Binding: Funds Reservation Codes (example)
... related SI0..*BackboneElementReplaced or Merged claim number (112 )
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... claim I0..1Reference(Claim)Reference to the related claim
.... relationship SI1..1CodeableConceptHow the reference claim is related
Binding: ExampleRelatedClaimRelationshipCodes (example)
.... reference I0..1IdentifierFile or case reference
... prescription I0..1Reference(MedicationRequest | VisionPrescription)Prescription authorizing services or products
... originalPrescription I0..1Reference(MedicationRequest)Original prescription if superceded by fulfiller
... payee SI0..1BackboneElementRecipient of benefits payable
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... type SI1..1CodeableConceptIdentifies recipient of benefits payable; i.e., provider or subscriber (120 )
Binding: Claim Payee Type Codes (example)
.... party SI1..1Reference(CARIN BB Organization | CARIN BB Patient | CARIN BB Practitioner)Recipient reference (121 )
... referral I0..1Reference(ServiceRequest)Treatment Referral
... facility I0..1Reference(Location)Servicing Facility
... claim I0..1Reference(Claim)Claim reference
... claimResponse I0..1Reference(ClaimResponse)Claim response reference
... outcome ΣI1..1codequeued | complete | error | partial
Binding: ClaimProcessingCodes (required)
... disposition I0..1stringDisposition Message
... preAuthRef I0..*stringPreauthorization reference
... preAuthRefPeriod I0..*PeriodPreauthorization in-effect period
... careTeam SI0..*BackboneElementCare Team members
EOB-inst-careTeam-practitioner: Institutional EOB: Careteam roles refer to a practitioner
EOB-inst-careTeam-organization: Institutional EOB: Careteam roles refer to a practitioner
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence I1..1positiveIntOrder of care team
.... provider SI1..1Reference(CARIN BB Organization | CARIN BB Practitioner)The NPI of the referring physician. (99 )
.... responsible SI0..1booleanIndicator of the lead practitioner
.... role SI1..1CodeableConceptFunction within the team
Binding: CARINBB Institutional Claim Care Team Roles (required)
.... qualification I0..1CodeableConceptPractitioner credential or specialization
Binding: ExampleProviderQualificationCodes (example)
... supportingInfo SI0..*(Slice Definition)Supporting information
Slice: Unordered, Open by pattern:category
.... supportingInfo:All Slices Content/Rules for all slices
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence I1..1positiveIntInformation instance identifier
..... category I1..1CodeableConceptClassification of the supplied information
Binding: ClaimInformationCategoryCodes (example)
..... code SI0..1CodeableConceptPatient’s status as of the discharge date for a facility stay. Information located on UB04 (Form Locator 17). (117 )
Binding: ExceptionCodes (example)
..... timing[x] SI0..1When it occurred
...... timingDatedate
...... timingPeriodPeriod
..... value[x] SI0..1Data to be provided
...... valueBooleanboolean
...... valueStringstring
...... valueQuantityQuantity
...... valueAttachmentAttachment
...... valueReferenceReference(Resource)
..... reason I0..1CodingExplanation for the information
Binding: MissingToothReasonCodes (example)
.... supportingInfo:billingnetworkcontractingstatus SI0..1BackboneElementIndicates that the Billing Provider has a contract with the Plan (regardless of the network) as of the effective date of service or admission. (101 )
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence I1..1positiveIntInformation instance identifier
..... category I1..1CodeableConceptClassification of the supplied information
Binding: ClaimInformationCategoryCodes (example)
Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/ClaimInformationCategoryCS
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: billingnetworkcontractingstatus
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... code SI1..1CodeableConceptType of information
Binding: Provider Provider Contracting Status (required)
..... timing[x] SI0..1When it occurred
...... timingDatedate
...... timingPeriodPeriod
..... value[x] SI0..1Data to be provided
...... valueBooleanboolean
...... valueStringstring
...... valueQuantityQuantity
...... valueAttachmentAttachment
...... valueReferenceReference(Resource)
..... reason I0..1CodingExplanation for the information
Binding: MissingToothReasonCodes (example)
.... supportingInfo:attendingnetworkcontractingstatus SI0..1BackboneElementIndicates the network status of the attending physician (101 )
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence I1..1positiveIntInformation instance identifier
..... category I1..1CodeableConceptClassification of the supplied information
Binding: ClaimInformationCategoryCodes (example)
Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/ClaimInformationCategoryCS
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: attendingnetworkcontractingstatus
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... code SI1..1CodeableConceptType of information
Binding: Provider Provider Contracting Status (required)
..... timing[x] SI0..1When it occurred
...... timingDatedate
...... timingPeriodPeriod
..... value[x] SI0..1Data to be provided
...... valueBooleanboolean
...... valueStringstring
...... valueQuantityQuantity
...... valueAttachmentAttachment
...... valueReferenceReference(Resource)
..... reason I0..1CodingExplanation for the information
Binding: MissingToothReasonCodes (example)
.... supportingInfo:referringnetworkcontractingstatus SI0..1BackboneElementIndicates the network status of the referring physician (101 )
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence I1..1positiveIntInformation instance identifier
..... category I1..1CodeableConceptClassification of the supplied information
Binding: ClaimInformationCategoryCodes (example)
Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/ClaimInformationCategoryCS
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: referringnetworkcontractingstatus
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... code SI1..1CodeableConceptType of information
Binding: Provider Provider Contracting Status (required)
..... timing[x] SI0..1When it occurred
...... timingDatedate
...... timingPeriodPeriod
..... value[x] SI0..1Data to be provided
...... valueBooleanboolean
...... valueStringstring
...... valueQuantityQuantity
...... valueAttachmentAttachment
...... valueReferenceReference(Resource)
..... reason I0..1CodingExplanation for the information
Binding: MissingToothReasonCodes (example)
.... supportingInfo:supervisingnetworkcontractingstatus SI0..1BackboneElementSupporting information
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence I1..1positiveIntInformation instance identifier
..... category I1..1CodeableConceptClassification of the supplied information
Binding: ClaimInformationCategoryCodes (example)
Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/ClaimInformationCategoryCS
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: supervisingnetworkcontractingstatus
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... code SI1..1CodeableConceptType of information
Binding: Provider Provider Contracting Status (required)
..... timing[x] SI0..1When it occurred
...... timingDatedate
...... timingPeriodPeriod
..... value[x] SI0..1Data to be provided
...... valueBooleanboolean
...... valueStringstring
...... valueQuantityQuantity
...... valueAttachmentAttachment
...... valueReferenceReference(Resource)
..... reason I0..1CodingExplanation for the information
Binding: MissingToothReasonCodes (example)
.... supportingInfo:clmrecvddate SI0..1BackboneElementThe date the claim was received by the payer (88 )
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence I1..1positiveIntInformation instance identifier
..... category I1..1CodeableConceptClassification of the supplied information
Binding: ClaimInformationCategoryCodes (example)
Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/ClaimInformationCategoryCS
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: clmrecvddate
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... code SI0..1CodeableConceptType of information
Binding: ExceptionCodes (example)
..... timing[x] SI1..1dateWhen it occurred
..... value[x] SI0..1Data to be provided
...... valueBooleanboolean
...... valueStringstring
...... valueQuantityQuantity
...... valueAttachmentAttachment
...... valueReferenceReference(Resource)
..... reason I0..1CodingExplanation for the information
Binding: MissingToothReasonCodes (example)
.... supportingInfo:typeofbill SI0..1BackboneElementUB04 (Form Locator 4) type of bill code provides specific information for payer purposes. The first digit of the three-digit number denotes the type of facility, the second digit classifies the type of care being billed, and the third digit identifies the frequency of the bill for a specific course of treatment or inpatient confinement. (17 )
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence I1..1positiveIntInformation instance identifier
..... category I1..1CodeableConceptClassification of the supplied information
Binding: ClaimInformationCategoryCodes (example)
Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/ClaimInformationCategoryCS
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: typeofbill
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... code SI0..1CodeableConceptType of information
Binding: nubc-type-of-bill (required)
..... timing[x] SI0..1When it occurred
...... timingDatedate
...... timingPeriodPeriod
..... value[x] SI0..1Data to be provided
...... valueBooleanboolean
...... valueStringstring
...... valueQuantityQuantity
...... valueAttachmentAttachment
...... valueReferenceReference(Resource)
..... reason I0..1CodingExplanation for the information
Binding: MissingToothReasonCodes (example)
.... supportingInfo:pointoforigin SI0..1BackboneElementIdentifies the place where the patient was identified as needing admission to a facility. This is a two position code mapped from the standard values for the UB-04 Source of Admission code (FL-15). (13 )
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence I1..1positiveIntInformation instance identifier
..... category I1..1CodeableConceptClassification of the supplied information
Binding: ClaimInformationCategoryCodes (example)
Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/ClaimInformationCategoryCS
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: admsrc
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... code SI0..1CodeableConceptType of information
Binding: nubc-admission-source (required)
..... timing[x] SI0..1When it occurred
...... timingDatedate
...... timingPeriodPeriod
..... value[x] SI0..1Data to be provided
...... valueBooleanboolean
...... valueStringstring
...... valueQuantityQuantity
...... valueAttachmentAttachment
...... valueReferenceReference(Resource)
..... reason I0..1CodingExplanation for the information
Binding: MissingToothReasonCodes (example)
.... supportingInfo:admtype SI0..1BackboneElementClaim Priority (Type) of Admission or Visit
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence I1..1positiveIntInformation instance identifier
..... category I1..1CodeableConceptClassification of the supplied information
Binding: ClaimInformationCategoryCodes (example)
Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/ClaimInformationCategoryCS
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: admtype
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... code SI0..1CodeableConceptType of information
Binding: NUBC Priority of Admission (required)
..... timing[x] SI0..1When it occurred
...... timingDatedate
...... timingPeriodPeriod
..... value[x] SI0..1Data to be provided
...... valueBooleanboolean
...... valueStringstring
...... valueQuantityQuantity
...... valueAttachmentAttachment
...... valueReferenceReference(Resource)
..... reason I0..1CodingExplanation for the information
Binding: MissingToothReasonCodes (example)
.... supportingInfo:discharge-status SI0..1BackboneElementDischarge Status
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence I1..1positiveIntInformation instance identifier
..... category I1..1CodeableConceptClassification of the supplied information
Binding: ClaimInformationCategoryCodes (example)
Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/ClaimInformationCategoryCS
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: discharge-status
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... code SI0..1CodeableConceptType of information
Binding: NUBC Patient Discharge Status (required)
..... timing[x] SI0..1When it occurred
...... timingDatedate
...... timingPeriodPeriod
..... value[x] SI0..1Data to be provided
...... valueBooleanboolean
...... valueStringstring
...... valueQuantityQuantity
...... valueAttachmentAttachment
...... valueReferenceReference(Resource)
..... reason I0..1CodingExplanation for the information
Binding: MissingToothReasonCodes (example)
.... supportingInfo:drg SI0..1BackboneElementClaim diagnosis related group (DRG)
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence I1..1positiveIntInformation instance identifier
..... category I1..1CodeableConceptClassification of the supplied information
Binding: ClaimInformationCategoryCodes (example)
Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/ClaimInformationCategoryCS
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: drg
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... code SI0..1CodeableConceptType of information
Binding: CMS-DRG (required)
..... timing[x] SI0..1When it occurred
...... timingDatedate
...... timingPeriodPeriod
..... value[x] SI0..1Data to be provided
...... valueBooleanboolean
...... valueStringstring
...... valueQuantityQuantity
...... valueAttachmentAttachment
...... valueReferenceReference(Resource)
..... reason I0..1CodingExplanation for the information
Binding: MissingToothReasonCodes (example)
.... supportingInfo:onadmissiontype SI0..1BackboneElementOn Admission Type
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence I1..1positiveIntInformation instance identifier
..... category I1..1CodeableConceptClassification of the supplied information
Binding: ClaimInformationCategoryCodes (example)
..... code SI0..1CodeableConceptType of information
Binding: Payer Diagnosis Present On Admission Diagnosis Type (required)
..... timing[x] SI0..1When it occurred
...... timingDatedate
...... timingPeriodPeriod
..... value[x] SI0..1Data to be provided
...... valueBooleanboolean
...... valueStringstring
...... valueQuantityQuantity
...... valueAttachmentAttachment
...... valueReferenceReference(Resource)
..... reason I0..1CodingExplanation for the information
Binding: MissingToothReasonCodes (example)
... diagnosis SI1..*BackboneElementThis is the reason given by the patient for visiting the doctor or practitioner. It is not the doctor's or practitioner's diagnosis. Patient Reason for Visit Codes can be any ICD-10diagnosis and may or may not be a repeat of an ICD-10 Principal or Secondary diagnosis field. (31 )
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence I1..1positiveIntDiagnosis instance identifier
.... diagnosis[x] SI1..1CodeableConceptA plain text representation of the diagnosis (145 )
Binding: ICD-10-CM Diagnosis Codes (required)
.... type SI1..1CodeableConceptTiming or nature of the diagnosis
Binding: Diagnosis Type -- Inpatient Facility (required)
.... onAdmission SI0..1CodeableConceptUsed to capture whether a diagnosis was present at time of a patient's admission. This is used to group diagnoses into the proper DRG for all claims involving inpatient admissions to general acute care facilities. (28 )
Binding: NUBC Present On Admission (required)
.... packageCode I0..1CodeableConceptPackage billing code
Binding: ExampleDiagnosisRelatedGroupCodes (example)
... procedure SI0..*BackboneElementPrincipal medical procedure a patient received during inpatient stay. Coding methods for this field is International Classification of Diseases Surgical Procedures (ICD-10). (24 )
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence I1..1positiveIntProcedure instance identifier
.... type SI0..*CodeableConceptCategory of Procedure
Binding: ExampleProcedureTypeCodes (example)
.... date SI0..1dateTimeWhen the procedure was performed
.... procedure[x] SI1..1(Slice Definition)Specific clinical procedure
Slice: Unordered, Closed by type:$this
Binding: ICD-10ProcedureCodes (example)
..... procedure[x]:procedureCodeableConcept I0..1CodeableConceptSpecific clinical procedure
Binding: ICD-10-PCS (required)
.... udi I0..*Reference(Device)Unique device identifier
... precedence I0..1positiveIntPrecedence (primary, secondary, etc.)
... insurance SΣI1..*BackboneElementIdentifies the primary payer. For use only on secondary claims. (141 )
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... focal SΣI1..1booleanCoverage to be used for adjudication
.... coverage SΣI1..1Reference(CARIN BB Coverage)Unique identifier for a member assigned by the Payer. If members receive ID cards, that is the identifier that should be provided. (1 )
.... preAuthRef I0..*stringPrior authorization reference number
... accident I0..1BackboneElementDetails of the event
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... date I0..1dateWhen the incident occurred
.... type I0..1CodeableConceptThe nature of the accident
Binding: ActIncidentCode (extensible)
.... location[x] I0..1Where the event occurred
..... locationAddressAddress
..... locationReferenceReference(Location)
... item SI0..*BackboneElementProduct or service provided
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence SI1..1positiveIntLine identification number that represents the number assigned in a source system for identification and processing. (36 )
.... careTeamSequence I0..*positiveIntApplicable care team members
.... diagnosisSequence I0..*positiveIntApplicable diagnoses
.... procedureSequence I0..*positiveIntApplicable procedures
.... informationSequence I0..*positiveIntApplicable exception and supporting information
.... revenue SI0..1CodeableConceptCode used on the UB-04 (Form Locator 42) to identify a specific accommodation, ancillary service, or billing calculation related to the service being billed (86 )
Binding: nubc-service-line-revenue (required)
.... category I0..1CodeableConceptBenefit classification
Binding: BenefitCategoryCodes (example)
.... productOrService SI1..1CodeableConceptMedical procedure a patient received from a health care provider. Current coding methods include: CPT-4 and HCFA Common Procedure Coding System Level II - (HCPCSII). (40 )
Binding: AMA CPT and CMS HCPCS Procedure Codes (required)
.... modifier SI0..*CodeableConceptModifier(s) for the procedure represented on this line. Identifies special circumstances related to the performance of the service. (41 )
Binding: AMA CPT and CMS HCPCS Modifier Codes (required)
.... programCode I0..*CodeableConceptProgram the product or service is provided under
Binding: ExampleProgramReasonCodes (example)
.... serviced[x] I0..1Date or dates of service or product delivery
..... servicedDatedate
..... servicedPeriodPeriod
.... location[x] I0..1Place of service or where product was supplied
Binding: ExampleServicePlaceCodes (example)
..... locationCodeableConceptCodeableConcept
..... locationAddressAddress
..... locationReferenceReference(Location)
.... quantity SI0..1SimpleQuantityThe quantity of units, times, days, visits, services, or treatments for the service described by the HCPCS code, revenue code or procedure code, submitted by the provider. (42 )
.... unitPrice I0..1MoneyFee, charge or cost per item
.... factor I0..1decimalPrice scaling factor
.... net I0..1MoneyTotal item cost
.... udi I0..*Reference(Device)Unique device identifier
.... bodySite I0..1CodeableConceptAnatomical location
Binding: OralSiteCodes (example)
.... subSite I0..*CodeableConceptAnatomical sub-location
Binding: SurfaceCodes (example)
.... encounter I0..*Reference(Encounter)Encounters related to this billed item
.... noteNumber I0..*positiveIntApplicable note numbers
.... adjudication SI0..*(Slice Definition)The quantity of units, times, days, visits, services, or treatments allowed for the service described by the HCPCS code, revenue code or procedure code, submitted by the provider. (149 )
Slice: Unordered, Closed by pattern:$this
..... adjudication:All Slices Content/Rules for all slices
...... id 0..1stringUnique id for inter-element referencing
...... extension I0..*ExtensionAdditional content defined by implementations
...... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... category SI1..1CodeableConceptType of adjudication information
Binding: Claim Adjudication Category (required)
...... reason I0..1CodeableConceptExplanation of adjudication outcome
Binding: AdjudicationReasonCodes (example)
...... amount I0..1MoneyMonetary amount
...... value I0..1decimalNon-monitary value
..... adjudication:adjudicationamounttype SI0..*BackboneElementAmounts
...... id 0..1stringUnique id for inter-element referencing
...... extension I0..*ExtensionAdditional content defined by implementations
...... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... category SI1..1CodeableConceptType of adjudication information
Binding: Adjudication CARINBB Value Codes (required)
...... reason I0..1CodeableConceptExplanation of adjudication outcome
Binding: AdjudicationReasonCodes (example)
...... amount SI0..1MoneyMonetary amount
...... value I0..1decimalNon-monitary value
..... adjudication:denialreason SI0..1BackboneElementDenial Reason
...... id 0..1stringUnique id for inter-element referencing
...... extension I0..*ExtensionAdditional content defined by implementations
...... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... category SI1..1CodeableConceptType of adjudication information
Binding: Claim Adjudication Category (required)
Required Pattern: At least the following
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
........ id0..1stringUnique id for inter-element referencing
........ extension0..*ExtensionAdditional content defined by implementations
........ system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/ClaimAdjudicationCategoryCS
........ version0..1stringVersion of the system - if relevant
........ code1..1codeSymbol in syntax defined by the system
Fixed Value: denialreason
........ display0..1stringRepresentation defined by the system
........ userSelected0..1booleanIf this coding was chosen directly by the user
....... text0..1stringPlain text representation of the concept
...... reason I1..1CodeableConceptExplanation of adjudication outcome
Binding: Adjudication Denial Reason (required)
...... amount I0..1MoneyMonetary amount
...... value I0..1decimalNon-monitary value
..... adjudication:allowedunits SI0..1BackboneElementAllowed number of units
...... id 0..1stringUnique id for inter-element referencing
...... extension I0..*ExtensionAdditional content defined by implementations
...... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... category SI1..1CodeableConceptType of adjudication information
Binding: Claim Adjudication Category (required)
Required Pattern: At least the following
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
........ id0..1stringUnique id for inter-element referencing
........ extension0..*ExtensionAdditional content defined by implementations
........ system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/ClaimAdjudicationCategoryCS
........ version0..1stringVersion of the system - if relevant
........ code1..1codeSymbol in syntax defined by the system
Fixed Value: allowedunits
........ display0..1stringRepresentation defined by the system
........ userSelected0..1booleanIf this coding was chosen directly by the user
....... text0..1stringPlain text representation of the concept
...... reason I0..1CodeableConceptExplanation of adjudication outcome
Binding: AdjudicationReasonCodes (example)
...... amount I0..1MoneyMonetary amount
...... value I0..1decimalNon-monitary value
.... detail I0..*BackboneElementAdditional items
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence I1..1positiveIntProduct or service provided
..... revenue I0..1CodeableConceptRevenue or cost center code
Binding: ExampleRevenueCenterCodes (example)
..... category I0..1CodeableConceptBenefit classification
Binding: BenefitCategoryCodes (example)
..... productOrService I1..1CodeableConceptBilling, service, product, or drug code
Binding: USCLSCodes (example)
..... modifier I0..*CodeableConceptService/Product billing modifiers
Binding: ModifierTypeCodes (example)
..... programCode I0..*CodeableConceptProgram the product or service is provided under
Binding: ExampleProgramReasonCodes (example)
..... quantity I0..1SimpleQuantityCount of products or services
..... unitPrice I0..1MoneyFee, charge or cost per item
..... factor I0..1decimalPrice scaling factor
..... net I0..1MoneyTotal item cost
..... udi I0..*Reference(Device)Unique device identifier
..... noteNumber I0..*positiveIntApplicable note numbers
..... adjudication I0..*See adjudicationDetail level adjudication details
..... subDetail I0..*BackboneElementAdditional items
...... id 0..1stringUnique id for inter-element referencing
...... extension I0..*ExtensionAdditional content defined by implementations
...... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... sequence I1..1positiveIntProduct or service provided
...... revenue I0..1CodeableConceptRevenue or cost center code
Binding: ExampleRevenueCenterCodes (example)
...... category I0..1CodeableConceptBenefit classification
Binding: BenefitCategoryCodes (example)
...... productOrService I1..1CodeableConceptBilling, service, product, or drug code
Binding: USCLSCodes (example)
...... modifier I0..*CodeableConceptService/Product billing modifiers
Binding: ModifierTypeCodes (example)
...... programCode I0..*CodeableConceptProgram the product or service is provided under
Binding: ExampleProgramReasonCodes (example)
...... quantity I0..1SimpleQuantityCount of products or services
...... unitPrice I0..1MoneyFee, charge or cost per item
...... factor I0..1decimalPrice scaling factor
...... net I0..1MoneyTotal item cost
...... udi I0..*Reference(Device)Unique device identifier
...... noteNumber I0..*positiveIntApplicable note numbers
...... adjudication I0..*See adjudicationSubdetail level adjudication details
... addItem I0..*BackboneElementInsurer added line items
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... itemSequence I0..*positiveIntItem sequence number
.... detailSequence I0..*positiveIntDetail sequence number
.... subDetailSequence I0..*positiveIntSubdetail sequence number
.... provider I0..*Reference(Practitioner | PractitionerRole | Organization)Authorized providers
.... productOrService I1..1CodeableConceptBilling, service, product, or drug code
Binding: USCLSCodes (example)
.... modifier I0..*CodeableConceptService/Product billing modifiers
Binding: ModifierTypeCodes (example)
.... programCode I0..*CodeableConceptProgram the product or service is provided under
Binding: ExampleProgramReasonCodes (example)
.... serviced[x] I0..1Date or dates of service or product delivery
..... servicedDatedate
..... servicedPeriodPeriod
.... location[x] I0..1Place of service or where product was supplied
Binding: ExampleServicePlaceCodes (example)
..... locationCodeableConceptCodeableConcept
..... locationAddressAddress
..... locationReferenceReference(Location)
.... quantity I0..1SimpleQuantityCount of products or services
.... unitPrice I0..1MoneyFee, charge or cost per item
.... factor I0..1decimalPrice scaling factor
.... net I0..1MoneyTotal item cost
.... bodySite I0..1CodeableConceptAnatomical location
Binding: OralSiteCodes (example)
.... subSite I0..*CodeableConceptAnatomical sub-location
Binding: SurfaceCodes (example)
.... noteNumber I0..*positiveIntApplicable note numbers
.... adjudication I0..*See adjudicationAdded items adjudication
.... detail I0..*BackboneElementInsurer added line items
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... productOrService I1..1CodeableConceptBilling, service, product, or drug code
Binding: USCLSCodes (example)
..... modifier I0..*CodeableConceptService/Product billing modifiers
Binding: ModifierTypeCodes (example)
..... quantity I0..1SimpleQuantityCount of products or services
..... unitPrice I0..1MoneyFee, charge or cost per item
..... factor I0..1decimalPrice scaling factor
..... net I0..1MoneyTotal item cost
..... noteNumber I0..*positiveIntApplicable note numbers
..... adjudication I0..*See adjudicationAdded items adjudication
..... subDetail I0..*BackboneElementInsurer added line items
...... id 0..1stringUnique id for inter-element referencing
...... extension I0..*ExtensionAdditional content defined by implementations
...... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... productOrService I1..1CodeableConceptBilling, service, product, or drug code
Binding: USCLSCodes (example)
...... modifier I0..*CodeableConceptService/Product billing modifiers
Binding: ModifierTypeCodes (example)
...... quantity I0..1SimpleQuantityCount of products or services
...... unitPrice I0..1MoneyFee, charge or cost per item
...... factor I0..1decimalPrice scaling factor
...... net I0..1MoneyTotal item cost
...... noteNumber I0..*positiveIntApplicable note numbers
...... adjudication I0..*See adjudicationAdded items adjudication
... adjudication SI0..*(Slice Definition)Header-level adjudication
Slice: Unordered, Closed by value:category
.... adjudication:All Slices Content/Rules for all slices
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category SI1..1CodeableConceptIndicates the in network or out of network payment status of the claim. (142 )
Binding: Claim Adjudication Category (required)
..... reason I0..1CodeableConceptExplanation of adjudication outcome
Binding: AdjudicationReasonCodes (example)
..... amount I0..1MoneyMonetary amount
..... value I0..1decimalNon-monitary value
.... adjudication:adjudicationamounttype SI0..*BackboneElementAmounts
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category I1..1CodeableConceptType of adjudication information
Binding: Adjudication CARINBB Value Codes (required)
..... reason I0..1CodeableConceptExplanation of adjudication outcome
Binding: AdjudicationReasonCodes (example)
..... amount I1..1MoneyMonetary amount
..... value I0..1decimalNon-monitary value
.... adjudication:denialreason SI0..1BackboneElementDenial Reason
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category I1..1CodeableConceptType of adjudication information
Binding: Claim Adjudication Category (required)
Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/ClaimAdjudicationCategoryCS
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: denialreason
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... reason I1..1CodeableConceptExplanation of adjudication outcome
Binding: Adjudication Denial Reason (required)
..... amount I0..1MoneyMonetary amount
..... value I0..1decimalNon-monitary value
... total ΣI1..*(Slice Definition)Adjudication totals
Slice: Unordered, Open by value:category
.... total:All Slices Content/Rules for all slices
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category SΣI1..1CodeableConceptType of adjudication information
Binding: Claim Adjudication Category (required)
..... amount SΣI1..1MoneyTotal amount for each category (i.e., submitted, allowed, etc.) (148 )
.... total:adjudicationamounttype SΣI0..*BackboneElementAmounts
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category ΣI1..1CodeableConceptType of adjudication information
Binding: Adjudication CARINBB Value Codes (required)
..... amount SΣI1..1MoneyFinancial total for the category
.... total:inoutnetwork SΣI1..1BackboneElementBenefit Payment Status
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category ΣI1..1CodeableConceptType of adjudication information
Binding: Benefit Payment Status (required)
..... amount SΣI1..1MoneyFinancial total for the category
... payment SI0..1BackboneElementPayment Details
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... type SI0..1CodeableConceptIndicates whether the claim was paid or denied. (91 )
Binding: Claim Payment Status Code (required)
.... adjustment I0..1MoneyPayment adjustment for non-claim issues
.... adjustmentReason SI0..1CodeableConceptReason codes used to interpret the Non-Covered Amount (92 )
Binding: PaymentAdjustmentReasonCodes (example)
.... date SI0..1dateThe date the claim was paid. (107 )
.... amount I0..1MoneyPayable amount after adjustment
.... identifier I0..1IdentifierBusiness identifier for the payment
... formCode I0..1CodeableConceptPrinted form identifier
Binding: Form Codes (example)
... form I0..1AttachmentPrinted reference or actual form
... processNote I0..*BackboneElementNote concerning adjudication
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... number I0..1positiveIntNote instance identifier
.... type I0..1codedisplay | print | printoper
Binding: NoteType (required)
.... text I0..1stringNote explanatory text
.... language I0..1CodeableConceptLanguage of the text
Binding: CommonLanguages (preferred)
Max Binding: AllLanguages
... benefitPeriod I0..1PeriodWhen the benefits are applicable
... benefitBalance I0..*BackboneElementBalance by Benefit Category
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... category I1..1CodeableConceptBenefit classification
Binding: BenefitCategoryCodes (example)
.... excluded I0..1booleanExcluded from the plan
.... name I0..1stringShort name for the benefit
.... description I0..1stringDescription of the benefit or services covered
.... network I0..1CodeableConceptIn or out of network
Binding: NetworkTypeCodes (example)
.... unit I0..1CodeableConceptIndividual or family
Binding: UnitTypeCodes (example)
.... term I0..1CodeableConceptAnnual or lifetime
Binding: BenefitTermCodes (example)
.... financial I0..*BackboneElementBenefit Summary
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... type I1..1CodeableConceptBenefit classification
Binding: BenefitTypeCodes (example)
..... allowed[x] I0..1Benefits allowed
...... allowedUnsignedIntunsignedInt
...... allowedStringstring
...... allowedMoneyMoney
..... used[x] I0..1Benefits used
...... usedUnsignedIntunsignedInt
...... usedMoneyMoney

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. ExplanationOfBenefit I0..*CARINBBExplanationOfBenefitExplanation of Benefit resource
... meta ΣI0..1MetaMetadata about the resource
.... lastUpdated ΣI1..1instantWhen the resource version last changed
.... profile ΣI1..*canonical(StructureDefinition)Profiles this resource claims to conform to
... identifier I1..*(Slice Definition)Claim identifier for a claim. (35 )
Slice: Unordered, Open by pattern:$this
.... identifier:claimnumber I1..1IdentifierClaim Number

Required Pattern: At least the following
..... id0..1stringUnique id for inter-element referencing
..... extension0..*ExtensionAdditional content defined by implementations
..... use0..1codeusual | official | temp | secondary | old (If known)
..... type1..1CodeableConceptDescription of identifier
Fixed Value: (complex)
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/IdentifierTypeCS
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: cn
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... system0..1uriThe namespace for the identifier value
..... value0..1stringThe value that is unique
..... period0..1PeriodTime period when id is/was valid for use
..... assigner0..1Reference(Organization)Organization that issued id (may be just text)
..... value ΣI1..1stringThe value that is unique
... status ?!ΣI1..1code (140 )
Binding: ExplanationOfBenefitStatus (required)
.... id0..1stringUnique id for inter-element referencing
.... extension0..*ExtensionAdditional content defined by implementations
.... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
..... id0..1stringUnique id for inter-element referencing
..... extension0..*ExtensionAdditional content defined by implementations
..... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type
..... version0..1stringVersion of the system - if relevant
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: institutional
..... display0..1stringRepresentation defined by the system
..... userSelected0..1booleanIf this coding was chosen directly by the user
.... text0..1stringPlain text representation of the concept
.... coding ΣI1..1CodingCode defined by a terminology system
... patient ΣI1..1Reference(CARIN BB Patient)Provider submitted information that can be included on the claim (110 )
... billablePeriod ΣI0..1PeriodIdentifies the date the patient was admitted/discharged for facility care (18,19 )
... insurer ΣI1..1Reference(CARIN BB Organization)Party responsible for reimbursement
... provider ΣI1..1Reference(CARIN BB Organization)The National Provider Identifier assigned to the Billing Provider. (94 )
... related I0..*BackboneElementReplaced or Merged claim number (112 )
.... relationship I1..1CodeableConceptHow the reference claim is related
Binding: ExampleRelatedClaimRelationshipCodes (example)
... payee I0..1BackboneElementRecipient of benefits payable
.... type I1..1CodeableConceptIdentifies recipient of benefits payable; i.e., provider or subscriber (120 )
Binding: Claim Payee Type Codes (example)
.... party I1..1Reference(CARIN BB Organization | CARIN BB Patient | CARIN BB Practitioner)Recipient reference (121 )
... careTeam I0..*BackboneElementCare Team members
EOB-inst-careTeam-practitioner: Institutional EOB: Careteam roles refer to a practitioner
EOB-inst-careTeam-organization: Institutional EOB: Careteam roles refer to a practitioner
.... provider I1..1Reference(CARIN BB Organization | CARIN BB Practitioner)The NPI of the referring physician. (99 )
.... responsible I0..1booleanIndicator of the lead practitioner
.... role I1..1CodeableConceptFunction within the team
Binding: CARINBB Institutional Claim Care Team Roles (required)
... supportingInfo I0..*(Slice Definition)Supporting information
Slice: Unordered, Open by pattern:category
.... supportingInfo:All Slices Content/Rules for all slices
..... code I0..1CodeableConceptPatient’s status as of the discharge date for a facility stay. Information located on UB04 (Form Locator 17). (117 )
Binding: ExceptionCodes (example)
..... timing[x] I0..1When it occurred
...... timingDatedate
...... timingPeriodPeriod
..... value[x] I0..1Data to be provided
...... valueBooleanboolean
...... valueStringstring
...... valueQuantityQuantity
...... valueAttachmentAttachment
...... valueReferenceReference(Resource)
.... supportingInfo:billingnetworkcontractingstatus I0..1BackboneElementIndicates that the Billing Provider has a contract with the Plan (regardless of the network) as of the effective date of service or admission. (101 )
..... code I1..1CodeableConceptType of information
Binding: Provider Provider Contracting Status (required)
..... timing[x] I0..1When it occurred
...... timingDatedate
...... timingPeriodPeriod
..... value[x] I0..1Data to be provided
...... valueBooleanboolean
...... valueStringstring
...... valueQuantityQuantity
...... valueAttachmentAttachment
...... valueReferenceReference(Resource)
.... supportingInfo:attendingnetworkcontractingstatus I0..1BackboneElementIndicates the network status of the attending physician (101 )
..... code I1..1CodeableConceptType of information
Binding: Provider Provider Contracting Status (required)
..... timing[x] I0..1When it occurred
...... timingDatedate
...... timingPeriodPeriod
..... value[x] I0..1Data to be provided
...... valueBooleanboolean
...... valueStringstring
...... valueQuantityQuantity
...... valueAttachmentAttachment
...... valueReferenceReference(Resource)
.... supportingInfo:referringnetworkcontractingstatus I0..1BackboneElementIndicates the network status of the referring physician (101 )
..... code I1..1CodeableConceptType of information
Binding: Provider Provider Contracting Status (required)
..... timing[x] I0..1When it occurred
...... timingDatedate
...... timingPeriodPeriod
..... value[x] I0..1Data to be provided
...... valueBooleanboolean
...... valueStringstring
...... valueQuantityQuantity
...... valueAttachmentAttachment
...... valueReferenceReference(Resource)
.... supportingInfo:supervisingnetworkcontractingstatus I0..1BackboneElementSupporting information
..... code I1..1CodeableConceptType of information
Binding: Provider Provider Contracting Status (required)
..... timing[x] I0..1When it occurred
...... timingDatedate
...... timingPeriodPeriod
..... value[x] I0..1Data to be provided
...... valueBooleanboolean
...... valueStringstring
...... valueQuantityQuantity
...... valueAttachmentAttachment
...... valueReferenceReference(Resource)
.... supportingInfo:clmrecvddate I0..1BackboneElementThe date the claim was received by the payer (88 )
..... code I0..1CodeableConceptType of information
Binding: ExceptionCodes (example)
..... timing[x] I1..1dateWhen it occurred
..... value[x] I0..1Data to be provided
...... valueBooleanboolean
...... valueStringstring
...... valueQuantityQuantity
...... valueAttachmentAttachment
...... valueReferenceReference(Resource)
.... supportingInfo:typeofbill I0..1BackboneElementUB04 (Form Locator 4) type of bill code provides specific information for payer purposes. The first digit of the three-digit number denotes the type of facility, the second digit classifies the type of care being billed, and the third digit identifies the frequency of the bill for a specific course of treatment or inpatient confinement. (17 )
..... code I0..1CodeableConceptType of information
Binding: nubc-type-of-bill (required)
..... timing[x] I0..1When it occurred
...... timingDatedate
...... timingPeriodPeriod
..... value[x] I0..1Data to be provided
...... valueBooleanboolean
...... valueStringstring
...... valueQuantityQuantity
...... valueAttachmentAttachment
...... valueReferenceReference(Resource)
.... supportingInfo:pointoforigin I0..1BackboneElementIdentifies the place where the patient was identified as needing admission to a facility. This is a two position code mapped from the standard values for the UB-04 Source of Admission code (FL-15). (13 )
..... code I0..1CodeableConceptType of information
Binding: nubc-admission-source (required)
..... timing[x] I0..1When it occurred
...... timingDatedate
...... timingPeriodPeriod
..... value[x] I0..1Data to be provided
...... valueBooleanboolean
...... valueStringstring
...... valueQuantityQuantity
...... valueAttachmentAttachment
...... valueReferenceReference(Resource)
.... supportingInfo:admtype I0..1BackboneElementClaim Priority (Type) of Admission or Visit
..... code I0..1CodeableConceptType of information
Binding: NUBC Priority of Admission (required)
..... timing[x] I0..1When it occurred
...... timingDatedate
...... timingPeriodPeriod
..... value[x] I0..1Data to be provided
...... valueBooleanboolean
...... valueStringstring
...... valueQuantityQuantity
...... valueAttachmentAttachment
...... valueReferenceReference(Resource)
.... supportingInfo:discharge-status I0..1BackboneElementDischarge Status
..... code I0..1CodeableConceptType of information
Binding: NUBC Patient Discharge Status (required)
..... timing[x] I0..1When it occurred
...... timingDatedate
...... timingPeriodPeriod
..... value[x] I0..1Data to be provided
...... valueBooleanboolean
...... valueStringstring
...... valueQuantityQuantity
...... valueAttachmentAttachment
...... valueReferenceReference(Resource)
.... supportingInfo:drg I0..1BackboneElementClaim diagnosis related group (DRG)
..... code I0..1CodeableConceptType of information
Binding: CMS-DRG (required)
..... timing[x] I0..1When it occurred
...... timingDatedate
...... timingPeriodPeriod
..... value[x] I0..1Data to be provided
...... valueBooleanboolean
...... valueStringstring
...... valueQuantityQuantity
...... valueAttachmentAttachment
...... valueReferenceReference(Resource)
.... supportingInfo:onadmissiontype I0..1BackboneElementOn Admission Type
..... code I0..1CodeableConceptType of information
Binding: Payer Diagnosis Present On Admission Diagnosis Type (required)
..... timing[x] I0..1When it occurred
...... timingDatedate
...... timingPeriodPeriod
..... value[x] I0..1Data to be provided
...... valueBooleanboolean
...... valueStringstring
...... valueQuantityQuantity
...... valueAttachmentAttachment
...... valueReferenceReference(Resource)
... diagnosis I1..*BackboneElementThis is the reason given by the patient for visiting the doctor or practitioner. It is not the doctor's or practitioner's diagnosis. Patient Reason for Visit Codes can be any ICD-10diagnosis and may or may not be a repeat of an ICD-10 Principal or Secondary diagnosis field. (31 )
.... diagnosis[x] I1..1CodeableConceptA plain text representation of the diagnosis (145 )
Binding: ICD-10-CM Diagnosis Codes (required)
.... type I1..1CodeableConceptTiming or nature of the diagnosis
Binding: Diagnosis Type -- Inpatient Facility (required)
.... onAdmission I0..1CodeableConceptUsed to capture whether a diagnosis was present at time of a patient's admission. This is used to group diagnoses into the proper DRG for all claims involving inpatient admissions to general acute care facilities. (28 )
Binding: NUBC Present On Admission (required)
... procedure I0..*BackboneElementPrincipal medical procedure a patient received during inpatient stay. Coding methods for this field is International Classification of Diseases Surgical Procedures (ICD-10). (24 )
.... type I0..*CodeableConceptCategory of Procedure
Binding: ExampleProcedureTypeCodes (example)
.... date I0..1dateTimeWhen the procedure was performed
.... procedure[x] I1..1(Slice Definition)Specific clinical procedure
Slice: Unordered, Closed by type:$this
Binding: ICD-10ProcedureCodes (example)
... insurance ΣI1..*BackboneElementIdentifies the primary payer. For use only on secondary claims. (141 )
.... focal ΣI1..1booleanCoverage to be used for adjudication
.... coverage ΣI1..1Reference(CARIN BB Coverage)Unique identifier for a member assigned by the Payer. If members receive ID cards, that is the identifier that should be provided. (1 )
... item I0..*BackboneElementProduct or service provided
.... sequence I1..1positiveIntLine identification number that represents the number assigned in a source system for identification and processing. (36 )
.... revenue I0..1CodeableConceptCode used on the UB-04 (Form Locator 42) to identify a specific accommodation, ancillary service, or billing calculation related to the service being billed (86 )
Binding: nubc-service-line-revenue (required)
.... productOrService I1..1CodeableConceptMedical procedure a patient received from a health care provider. Current coding methods include: CPT-4 and HCFA Common Procedure Coding System Level II - (HCPCSII). (40 )
Binding: AMA CPT and CMS HCPCS Procedure Codes (required)
.... modifier I0..*CodeableConceptModifier(s) for the procedure represented on this line. Identifies special circumstances related to the performance of the service. (41 )
Binding: AMA CPT and CMS HCPCS Modifier Codes (required)
.... quantity I0..1SimpleQuantityThe quantity of units, times, days, visits, services, or treatments for the service described by the HCPCS code, revenue code or procedure code, submitted by the provider. (42 )
.... adjudication I0..*(Slice Definition)The quantity of units, times, days, visits, services, or treatments allowed for the service described by the HCPCS code, revenue code or procedure code, submitted by the provider. (149 )
Slice: Unordered, Closed by pattern:$this
..... adjudication:All Slices Content/Rules for all slices
...... category I1..1CodeableConceptType of adjudication information
Binding: Claim Adjudication Category (required)
..... adjudication:adjudicationamounttype I0..*BackboneElementAmounts
...... category I1..1CodeableConceptType of adjudication information
Binding: Adjudication CARINBB Value Codes (required)
...... amount I0..1MoneyMonetary amount
..... adjudication:denialreason I0..1BackboneElementDenial Reason
...... category I1..1CodeableConceptType of adjudication information
Binding: Claim Adjudication Category (required)
Required Pattern: At least the following
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
........ id0..1stringUnique id for inter-element referencing
........ extension0..*ExtensionAdditional content defined by implementations
........ system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/ClaimAdjudicationCategoryCS
........ version0..1stringVersion of the system - if relevant
........ code1..1codeSymbol in syntax defined by the system
Fixed Value: denialreason
........ display0..1stringRepresentation defined by the system
........ userSelected0..1booleanIf this coding was chosen directly by the user
....... text0..1stringPlain text representation of the concept
..... adjudication:allowedunits I0..1BackboneElementAllowed number of units
...... category I1..1CodeableConceptType of adjudication information
Binding: Claim Adjudication Category (required)
Required Pattern: At least the following
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
........ id0..1stringUnique id for inter-element referencing
........ extension0..*ExtensionAdditional content defined by implementations
........ system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/ClaimAdjudicationCategoryCS
........ version0..1stringVersion of the system - if relevant
........ code1..1codeSymbol in syntax defined by the system
Fixed Value: allowedunits
........ display0..1stringRepresentation defined by the system
........ userSelected0..1booleanIf this coding was chosen directly by the user
....... text0..1stringPlain text representation of the concept
... adjudication I0..*(Slice Definition)Header-level adjudication
Slice: Unordered, Closed by value:category
.... adjudication:All Slices Content/Rules for all slices
..... category I1..1CodeableConceptIndicates the in network or out of network payment status of the claim. (142 )
Binding: Claim Adjudication Category (required)
.... adjudication:adjudicationamounttype I0..*BackboneElementAmounts
.... adjudication:denialreason I0..1BackboneElementDenial Reason
... total ΣI1..*(Slice Definition)Adjudication totals
Slice: Unordered, Open by value:category
.... total:All Slices Content/Rules for all slices
..... category ΣI1..1CodeableConceptType of adjudication information
Binding: Claim Adjudication Category (required)
..... amount ΣI1..1MoneyTotal amount for each category (i.e., submitted, allowed, etc.) (148 )
.... total:adjudicationamounttype ΣI0..*BackboneElementAmounts
..... amount ΣI1..1MoneyFinancial total for the category
.... total:inoutnetwork ΣI1..1BackboneElementBenefit Payment Status
..... amount ΣI1..1MoneyFinancial total for the category
... payment I0..1BackboneElementPayment Details
.... type I0..1CodeableConceptIndicates whether the claim was paid or denied. (91 )
Binding: Claim Payment Status Code (required)
.... adjustmentReason I0..1CodeableConceptReason codes used to interpret the Non-Covered Amount (92 )
Binding: PaymentAdjustmentReasonCodes (example)
.... date I0..1dateThe date the claim was paid. (107 )

doco Documentation for this format

This structure is derived from CARINBBExplanationOfBenefit

Summary

Mandatory: 5 elements (8 nested mandatory elements)
Must-Support: 24 elements

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element ExplanationOfBenefit.supportingInfo is sliced based on the value of pattern:category
  • The element ExplanationOfBenefit.procedure.procedure[x] is sliced based on the value of type:$this
  • The element ExplanationOfBenefit.item.adjudication is sliced based on the value of pattern:$this (Closed)
  • The element ExplanationOfBenefit.adjudication is sliced based on the value of value:category (Closed)
  • The element ExplanationOfBenefit.total is sliced based on the value of value:category

Differential View

This structure is derived from CARINBBExplanationOfBenefit

NameFlagsCard.TypeDescription & Constraintsdoco
.. ExplanationOfBenefit 0..*CARINBBExplanationOfBenefitExplanation of Benefit resource
... identifier S1..*IdentifierClaim identifier for a claim. (35 )
... status S1..1code (140 )
... type 1..1CodeableConceptSpecifies the type of claim. (e.g., inpatient insitutional, outpatient institutional, physician, etc.). (16 )
Required Pattern: At least the following
.... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
..... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: institutional
.... coding S1..1CodingCode defined by a terminology system
... billablePeriod 0..1PeriodIdentifies the date the patient was admitted/discharged for facility care (18,19 )
... provider 1..1Reference(CARIN BB Organization)The National Provider Identifier assigned to the Billing Provider. (94 )
... related 0..*BackboneElementReplaced or Merged claim number (112 )
... payee
.... type 1..1CodeableConceptIdentifies recipient of benefits payable; i.e., provider or subscriber (120 )
.... party 1..1Reference(CARIN BB Organization | CARIN BB Patient | CARIN BB Practitioner)Recipient reference (121 )
... careTeam I0..*BackboneElementCare Team members
EOB-inst-careTeam-practitioner: Institutional EOB: Careteam roles refer to a practitioner
EOB-inst-careTeam-organization: Institutional EOB: Careteam roles refer to a practitioner
.... provider 1..1Reference(CARIN BB Organization | CARIN BB Practitioner)The NPI of the referring physician. (99 )
.... role 1..1CodeableConceptFunction within the team
Binding: CARINBB Institutional Claim Care Team Roles (required)
... supportingInfo 0..*(Slice Definition)Supporting information
Slice: Unordered, Open by pattern:category
.... supportingInfo:All Slices Content/Rules for all slices
..... code 0..1CodeableConceptPatient’s status as of the discharge date for a facility stay. Information located on UB04 (Form Locator 17). (117 )
.... supportingInfo:billingnetworkcontractingstatus 0..1BackboneElementIndicates that the Billing Provider has a contract with the Plan (regardless of the network) as of the effective date of service or admission. (101 )
..... category 1..1CodeableConceptClassification of the supplied information
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/ClaimInformationCategoryCS
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: billingnetworkcontractingstatus
..... code 1..1CodeableConceptType of information
Binding: Provider Provider Contracting Status (required)
.... supportingInfo:attendingnetworkcontractingstatus 0..1BackboneElementIndicates the network status of the attending physician (101 )
..... category 1..1CodeableConceptClassification of the supplied information
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/ClaimInformationCategoryCS
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: attendingnetworkcontractingstatus
..... code 1..1CodeableConceptType of information
Binding: Provider Provider Contracting Status (required)
.... supportingInfo:referringnetworkcontractingstatus 0..1BackboneElementIndicates the network status of the referring physician (101 )
..... category 1..1CodeableConceptClassification of the supplied information
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/ClaimInformationCategoryCS
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: referringnetworkcontractingstatus
..... code 1..1CodeableConceptType of information
Binding: Provider Provider Contracting Status (required)
.... supportingInfo:supervisingnetworkcontractingstatus 0..1BackboneElementSupporting information
..... category 1..1CodeableConceptClassification of the supplied information
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/ClaimInformationCategoryCS
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: supervisingnetworkcontractingstatus
..... code 1..1CodeableConceptType of information
Binding: Provider Provider Contracting Status (required)
.... supportingInfo:clmrecvddate 0..1BackboneElementThe date the claim was received by the payer (88 )
..... category 1..1CodeableConceptClassification of the supplied information
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/ClaimInformationCategoryCS
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: clmrecvddate
..... timing[x] 1..1dateWhen it occurred
.... supportingInfo:typeofbill 0..1BackboneElementUB04 (Form Locator 4) type of bill code provides specific information for payer purposes. The first digit of the three-digit number denotes the type of facility, the second digit classifies the type of care being billed, and the third digit identifies the frequency of the bill for a specific course of treatment or inpatient confinement. (17 )
..... category 1..1CodeableConceptClassification of the supplied information
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/ClaimInformationCategoryCS
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: typeofbill
..... code 0..1CodeableConceptType of information
Binding: nubc-type-of-bill (required)
.... supportingInfo:pointoforigin 0..1BackboneElementIdentifies the place where the patient was identified as needing admission to a facility. This is a two position code mapped from the standard values for the UB-04 Source of Admission code (FL-15). (13 )
..... category 1..1CodeableConceptClassification of the supplied information
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/ClaimInformationCategoryCS
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: admsrc
..... code 0..1CodeableConceptType of information
Binding: nubc-admission-source (required)
.... supportingInfo:admtype 0..1BackboneElementClaim Priority (Type) of Admission or Visit
..... category 1..1CodeableConceptClassification of the supplied information
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/ClaimInformationCategoryCS
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: admtype
..... code 0..1CodeableConceptType of information
Binding: NUBC Priority of Admission (required)
.... supportingInfo:discharge-status 0..1BackboneElementDischarge Status
..... category 1..1CodeableConceptClassification of the supplied information
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/ClaimInformationCategoryCS
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: discharge-status
..... code 0..1CodeableConceptType of information
Binding: NUBC Patient Discharge Status (required)
.... supportingInfo:drg 0..1BackboneElementClaim diagnosis related group (DRG)
..... category 1..1CodeableConceptClassification of the supplied information
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/ClaimInformationCategoryCS
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: drg
..... code 0..1CodeableConceptType of information
Binding: CMS-DRG (required)
.... supportingInfo:onadmissiontype 0..1BackboneElementOn Admission Type
..... code 0..1CodeableConceptType of information
Binding: Payer Diagnosis Present On Admission Diagnosis Type (required)
... diagnosis S1..*BackboneElementThis is the reason given by the patient for visiting the doctor or practitioner. It is not the doctor's or practitioner's diagnosis. Patient Reason for Visit Codes can be any ICD-10diagnosis and may or may not be a repeat of an ICD-10 Principal or Secondary diagnosis field. (31 )
.... diagnosis[x] S1..1CodeableConceptA plain text representation of the diagnosis (145 )
Binding: ICD-10-CM Diagnosis Codes (required)
.... type S1..1CodeableConceptTiming or nature of the diagnosis
Binding: Diagnosis Type -- Inpatient Facility (required)
.... onAdmission S0..1CodeableConceptUsed to capture whether a diagnosis was present at time of a patient's admission. This is used to group diagnoses into the proper DRG for all claims involving inpatient admissions to general acute care facilities. (28 )
Binding: NUBC Present On Admission (required)
... procedure 0..*BackboneElementPrincipal medical procedure a patient received during inpatient stay. Coding methods for this field is International Classification of Diseases Surgical Procedures (ICD-10). (24 )
.... procedure[x] S1..1(Slice Definition)Specific clinical procedure
Slice: Unordered, Open by type:$this
.... procedureCodeableConcept 0..1CodeableConceptSpecific clinical procedure
Binding: ICD-10-PCS (required)
... insurance 1..*BackboneElementIdentifies the primary payer. For use only on secondary claims. (141 )
.... coverage 1..1Reference(CARIN BB Coverage)Unique identifier for a member assigned by the Payer. If members receive ID cards, that is the identifier that should be provided. (1 )
... item
.... sequence S1..1positiveIntLine identification number that represents the number assigned in a source system for identification and processing. (36 )
.... revenue S0..1CodeableConceptCode used on the UB-04 (Form Locator 42) to identify a specific accommodation, ancillary service, or billing calculation related to the service being billed (86 )
Binding: nubc-service-line-revenue (required)
.... productOrService S1..1CodeableConceptMedical procedure a patient received from a health care provider. Current coding methods include: CPT-4 and HCFA Common Procedure Coding System Level II - (HCPCSII). (40 )
Binding: AMA CPT and CMS HCPCS Procedure Codes (required)
.... modifier S0..*CodeableConceptModifier(s) for the procedure represented on this line. Identifies special circumstances related to the performance of the service. (41 )
Binding: AMA CPT and CMS HCPCS Modifier Codes (required)
.... quantity S0..1SimpleQuantityThe quantity of units, times, days, visits, services, or treatments for the service described by the HCPCS code, revenue code or procedure code, submitted by the provider. (42 )
.... adjudication 0..*(Slice Definition)The quantity of units, times, days, visits, services, or treatments allowed for the service described by the HCPCS code, revenue code or procedure code, submitted by the provider. (149 )
Slice: Unordered, Closed by pattern:$this
..... adjudication:adjudicationamounttype 0..*BackboneElementAmounts
...... category 1..1CodeableConceptType of adjudication information
Binding: Adjudication CARINBB Value Codes (required)
...... amount S0..1MoneyMonetary amount
..... adjudication:denialreason 0..1BackboneElementDenial Reason
...... category 1..1CodeableConceptType of adjudication information
Required Pattern: At least the following
....... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
........ system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/ClaimAdjudicationCategoryCS
........ code1..1codeSymbol in syntax defined by the system
Fixed Value: denialreason
...... reason 1..1CodeableConceptExplanation of adjudication outcome
Binding: Adjudication Denial Reason (required)
..... adjudication:allowedunits 0..1BackboneElementAllowed number of units
...... category 1..1CodeableConceptType of adjudication information
Required Pattern: At least the following
....... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
........ system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/ClaimAdjudicationCategoryCS
........ code1..1codeSymbol in syntax defined by the system
Fixed Value: allowedunits
... adjudication 0..*(Slice Definition)Header-level adjudication
Slice: Unordered, Closed by value:category
.... adjudication:All Slices Content/Rules for all slices
..... category S1..1CodeableConceptIndicates the in network or out of network payment status of the claim. (142 )
.... adjudication:adjudicationamounttype 0..*BackboneElementAmounts
..... category 1..1CodeableConceptType of adjudication information
Binding: Adjudication CARINBB Value Codes (required)
..... amount 1..1MoneyMonetary amount
.... adjudication:denialreason 0..1BackboneElementDenial Reason
..... category 1..1CodeableConceptType of adjudication information
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/ClaimAdjudicationCategoryCS
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: denialreason
..... reason 1..1CodeableConceptExplanation of adjudication outcome
Binding: Adjudication Denial Reason (required)
... total 1..*(Slice Definition)Adjudication totals
Slice: Unordered, Open by value:category
.... total:All Slices Content/Rules for all slices
..... category S1..1CodeableConceptType of adjudication information
..... amount S1..1MoneyTotal amount for each category (i.e., submitted, allowed, etc.) (148 )
.... total:adjudicationamounttype S0..*BackboneElementAmounts
..... category 1..1CodeableConceptType of adjudication information
Binding: Adjudication CARINBB Value Codes (required)
..... amount S1..1MoneyFinancial total for the category
.... total:inoutnetwork S1..1BackboneElementBenefit Payment Status
..... category 1..1CodeableConceptType of adjudication information
Binding: Benefit Payment Status (required)
..... amount S1..1MoneyFinancial total for the category
... payment
.... type S0..1CodeableConceptIndicates whether the claim was paid or denied. (91 )
.... adjustmentReason S0..1CodeableConceptReason codes used to interpret the Non-Covered Amount (92 )
.... date S0..1dateThe date the claim was paid. (107 )

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. ExplanationOfBenefit I0..*CARINBBExplanationOfBenefitExplanation of Benefit resource
... id Σ0..1stringLogical id of this artifact
... meta ΣI0..1MetaMetadata about the resource
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... versionId ΣI0..1idVersion specific identifier
.... lastUpdated SΣI1..1instantWhen the resource version last changed
.... source ΣI0..1uriIdentifies where the resource comes from
.... profile SΣI1..*canonical(StructureDefinition)Profiles this resource claims to conform to
.... security ΣI0..*CodingSecurity Labels applied to this resource
Binding: All Security Labels (extensible)
.... tag ΣI0..*CodingTags applied to this resource
Binding: CommonTags (example)
... implicitRules ?!ΣI0..1uriA set of rules under which this content was created
... language I0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred)
Max Binding: AllLanguages
... text I0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension I0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!I0..*ExtensionExtensions that cannot be ignored
... identifier SI1..*(Slice Definition)Claim identifier for a claim. (35 )
Slice: Unordered, Open by pattern:$this
.... identifier:claimnumber SI1..1IdentifierClaim Number

Required Pattern: At least the following
..... id0..1stringUnique id for inter-element referencing
..... extension0..*ExtensionAdditional content defined by implementations
..... use0..1codeusual | official | temp | secondary | old (If known)
..... type1..1CodeableConceptDescription of identifier
Fixed Value: (complex)
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/IdentifierTypeCS
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: cn
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... system0..1uriThe namespace for the identifier value
..... value0..1stringThe value that is unique
..... period0..1PeriodTime period when id is/was valid for use
..... assigner0..1Reference(Organization)Organization that issued id (may be just text)
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... use ?!ΣI0..1codeusual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required)
..... type ΣI0..1CodeableConceptDescription of identifier
Binding: Identifier Type Codes (extensible)
..... system ΣI0..1uriThe namespace for the identifier value
Example General: http://www.acme.com/identifiers/patient
..... value SΣI1..1stringThe value that is unique
Example General: 123456
..... period ΣI0..1PeriodTime period when id is/was valid for use
..... assigner ΣI0..1Reference(Organization)Organization that issued id (may be just text)
... status ?!SΣI1..1code (140 )
Binding: ExplanationOfBenefitStatus (required)
... type SΣI1..1CodeableConceptSpecifies the type of claim. (e.g., inpatient insitutional, outpatient institutional, physician, etc.). (16 )
Binding: ClaimTypeCodes (required)
Required Pattern: At least the following
.... id0..1stringUnique id for inter-element referencing
.... extension0..*ExtensionAdditional content defined by implementations
.... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
..... id0..1stringUnique id for inter-element referencing
..... extension0..*ExtensionAdditional content defined by implementations
..... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type
..... version0..1stringVersion of the system - if relevant
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: institutional
..... display0..1stringRepresentation defined by the system
..... userSelected0..1booleanIf this coding was chosen directly by the user
.... text0..1stringPlain text representation of the concept
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... coding SΣI1..1CodingCode defined by a terminology system
.... text ΣI0..1stringPlain text representation of the concept
... subType I0..1CodeableConceptMore granular claim type
Binding: ExampleClaimSubTypeCodes (example)
... use ΣI1..1codeclaim | preauthorization | predetermination
Binding: Use (required)
Required Pattern: claim
... patient SΣI1..1Reference(CARIN BB Patient)Provider submitted information that can be included on the claim (110 )
... billablePeriod SΣI0..1PeriodIdentifies the date the patient was admitted/discharged for facility care (18,19 )
... created ΣI1..1dateTimeResponse creation date
... enterer I0..1Reference(Practitioner | PractitionerRole)Author of the claim
... insurer SΣI1..1Reference(CARIN BB Organization)Party responsible for reimbursement
... provider SΣI1..1Reference(CARIN BB Organization)The National Provider Identifier assigned to the Billing Provider. (94 )
... priority I0..1CodeableConceptDesired processing urgency
Binding: http://terminology.hl7.org/CodeSystem/processpriority (example)
... fundsReserveRequested I0..1CodeableConceptFor whom to reserve funds
Binding: Funds Reservation Codes (example)
... fundsReserve I0..1CodeableConceptFunds reserved status
Binding: Funds Reservation Codes (example)
... related SI0..*BackboneElementReplaced or Merged claim number (112 )
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... claim I0..1Reference(Claim)Reference to the related claim
.... relationship SI1..1CodeableConceptHow the reference claim is related
Binding: ExampleRelatedClaimRelationshipCodes (example)
.... reference I0..1IdentifierFile or case reference
... prescription I0..1Reference(MedicationRequest | VisionPrescription)Prescription authorizing services or products
... originalPrescription I0..1Reference(MedicationRequest)Original prescription if superceded by fulfiller
... payee SI0..1BackboneElementRecipient of benefits payable
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... type SI1..1CodeableConceptIdentifies recipient of benefits payable; i.e., provider or subscriber (120 )
Binding: Claim Payee Type Codes (example)
.... party SI1..1Reference(CARIN BB Organization | CARIN BB Patient | CARIN BB Practitioner)Recipient reference (121 )
... referral I0..1Reference(ServiceRequest)Treatment Referral
... facility I0..1Reference(Location)Servicing Facility
... claim I0..1Reference(Claim)Claim reference
... claimResponse I0..1Reference(ClaimResponse)Claim response reference
... outcome ΣI1..1codequeued | complete | error | partial
Binding: ClaimProcessingCodes (required)
... disposition I0..1stringDisposition Message
... preAuthRef I0..*stringPreauthorization reference
... preAuthRefPeriod I0..*PeriodPreauthorization in-effect period
... careTeam SI0..*BackboneElementCare Team members
EOB-inst-careTeam-practitioner: Institutional EOB: Careteam roles refer to a practitioner
EOB-inst-careTeam-organization: Institutional EOB: Careteam roles refer to a practitioner
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence I1..1positiveIntOrder of care team
.... provider SI1..1Reference(CARIN BB Organization | CARIN BB Practitioner)The NPI of the referring physician. (99 )
.... responsible SI0..1booleanIndicator of the lead practitioner
.... role SI1..1CodeableConceptFunction within the team
Binding: CARINBB Institutional Claim Care Team Roles (required)
.... qualification I0..1CodeableConceptPractitioner credential or specialization
Binding: ExampleProviderQualificationCodes (example)
... supportingInfo SI0..*(Slice Definition)Supporting information
Slice: Unordered, Open by pattern:category
.... supportingInfo:All Slices Content/Rules for all slices
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence I1..1positiveIntInformation instance identifier
..... category I1..1CodeableConceptClassification of the supplied information
Binding: ClaimInformationCategoryCodes (example)
..... code SI0..1CodeableConceptPatient’s status as of the discharge date for a facility stay. Information located on UB04 (Form Locator 17). (117 )
Binding: ExceptionCodes (example)
..... timing[x] SI0..1When it occurred
...... timingDatedate
...... timingPeriodPeriod
..... value[x] SI0..1Data to be provided
...... valueBooleanboolean
...... valueStringstring
...... valueQuantityQuantity
...... valueAttachmentAttachment
...... valueReferenceReference(Resource)
..... reason I0..1CodingExplanation for the information
Binding: MissingToothReasonCodes (example)
.... supportingInfo:billingnetworkcontractingstatus SI0..1BackboneElementIndicates that the Billing Provider has a contract with the Plan (regardless of the network) as of the effective date of service or admission. (101 )
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence I1..1positiveIntInformation instance identifier
..... category I1..1CodeableConceptClassification of the supplied information
Binding: ClaimInformationCategoryCodes (example)
Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/ClaimInformationCategoryCS
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: billingnetworkcontractingstatus
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... code SI1..1CodeableConceptType of information
Binding: Provider Provider Contracting Status (required)
..... timing[x] SI0..1When it occurred
...... timingDatedate
...... timingPeriodPeriod
..... value[x] SI0..1Data to be provided
...... valueBooleanboolean
...... valueStringstring
...... valueQuantityQuantity
...... valueAttachmentAttachment
...... valueReferenceReference(Resource)
..... reason I0..1CodingExplanation for the information
Binding: MissingToothReasonCodes (example)
.... supportingInfo:attendingnetworkcontractingstatus SI0..1BackboneElementIndicates the network status of the attending physician (101 )
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence I1..1positiveIntInformation instance identifier
..... category I1..1CodeableConceptClassification of the supplied information
Binding: ClaimInformationCategoryCodes (example)
Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/ClaimInformationCategoryCS
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: attendingnetworkcontractingstatus
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... code SI1..1CodeableConceptType of information
Binding: Provider Provider Contracting Status (required)
..... timing[x] SI0..1When it occurred
...... timingDatedate
...... timingPeriodPeriod
..... value[x] SI0..1Data to be provided
...... valueBooleanboolean
...... valueStringstring
...... valueQuantityQuantity
...... valueAttachmentAttachment
...... valueReferenceReference(Resource)
..... reason I0..1CodingExplanation for the information
Binding: MissingToothReasonCodes (example)
.... supportingInfo:referringnetworkcontractingstatus SI0..1BackboneElementIndicates the network status of the referring physician (101 )
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence I1..1positiveIntInformation instance identifier
..... category I1..1CodeableConceptClassification of the supplied information
Binding: ClaimInformationCategoryCodes (example)
Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/ClaimInformationCategoryCS
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: referringnetworkcontractingstatus
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... code SI1..1CodeableConceptType of information
Binding: Provider Provider Contracting Status (required)
..... timing[x] SI0..1When it occurred
...... timingDatedate
...... timingPeriodPeriod
..... value[x] SI0..1Data to be provided
...... valueBooleanboolean
...... valueStringstring
...... valueQuantityQuantity
...... valueAttachmentAttachment
...... valueReferenceReference(Resource)
..... reason I0..1CodingExplanation for the information
Binding: MissingToothReasonCodes (example)
.... supportingInfo:supervisingnetworkcontractingstatus SI0..1BackboneElementSupporting information
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence I1..1positiveIntInformation instance identifier
..... category I1..1CodeableConceptClassification of the supplied information
Binding: ClaimInformationCategoryCodes (example)
Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/ClaimInformationCategoryCS
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: supervisingnetworkcontractingstatus
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... code SI1..1CodeableConceptType of information
Binding: Provider Provider Contracting Status (required)
..... timing[x] SI0..1When it occurred
...... timingDatedate
...... timingPeriodPeriod
..... value[x] SI0..1Data to be provided
...... valueBooleanboolean
...... valueStringstring
...... valueQuantityQuantity
...... valueAttachmentAttachment
...... valueReferenceReference(Resource)
..... reason I0..1CodingExplanation for the information
Binding: MissingToothReasonCodes (example)
.... supportingInfo:clmrecvddate SI0..1BackboneElementThe date the claim was received by the payer (88 )
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence I1..1positiveIntInformation instance identifier
..... category I1..1CodeableConceptClassification of the supplied information
Binding: ClaimInformationCategoryCodes (example)
Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/ClaimInformationCategoryCS
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: clmrecvddate
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... code SI0..1CodeableConceptType of information
Binding: ExceptionCodes (example)
..... timing[x] SI1..1dateWhen it occurred
..... value[x] SI0..1Data to be provided
...... valueBooleanboolean
...... valueStringstring
...... valueQuantityQuantity
...... valueAttachmentAttachment
...... valueReferenceReference(Resource)
..... reason I0..1CodingExplanation for the information
Binding: MissingToothReasonCodes (example)
.... supportingInfo:typeofbill SI0..1BackboneElementUB04 (Form Locator 4) type of bill code provides specific information for payer purposes. The first digit of the three-digit number denotes the type of facility, the second digit classifies the type of care being billed, and the third digit identifies the frequency of the bill for a specific course of treatment or inpatient confinement. (17 )
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence I1..1positiveIntInformation instance identifier
..... category I1..1CodeableConceptClassification of the supplied information
Binding: ClaimInformationCategoryCodes (example)
Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/ClaimInformationCategoryCS
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: typeofbill
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... code SI0..1CodeableConceptType of information
Binding: nubc-type-of-bill (required)
..... timing[x] SI0..1When it occurred
...... timingDatedate
...... timingPeriodPeriod
..... value[x] SI0..1Data to be provided
...... valueBooleanboolean
...... valueStringstring
...... valueQuantityQuantity
...... valueAttachmentAttachment
...... valueReferenceReference(Resource)
..... reason I0..1CodingExplanation for the information
Binding: MissingToothReasonCodes (example)
.... supportingInfo:pointoforigin SI0..1BackboneElementIdentifies the place where the patient was identified as needing admission to a facility. This is a two position code mapped from the standard values for the UB-04 Source of Admission code (FL-15). (13 )
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence I1..1positiveIntInformation instance identifier
..... category I1..1CodeableConceptClassification of the supplied information
Binding: ClaimInformationCategoryCodes (example)
Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/ClaimInformationCategoryCS
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: admsrc
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... code SI0..1CodeableConceptType of information
Binding: nubc-admission-source (required)
..... timing[x] SI0..1When it occurred
...... timingDatedate
...... timingPeriodPeriod
..... value[x] SI0..1Data to be provided
...... valueBooleanboolean
...... valueStringstring
...... valueQuantityQuantity
...... valueAttachmentAttachment
...... valueReferenceReference(Resource)
..... reason I0..1CodingExplanation for the information
Binding: MissingToothReasonCodes (example)
.... supportingInfo:admtype SI0..1BackboneElementClaim Priority (Type) of Admission or Visit
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence I1..1positiveIntInformation instance identifier
..... category I1..1CodeableConceptClassification of the supplied information
Binding: ClaimInformationCategoryCodes (example)
Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/ClaimInformationCategoryCS
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: admtype
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... code SI0..1CodeableConceptType of information
Binding: NUBC Priority of Admission (required)
..... timing[x] SI0..1When it occurred
...... timingDatedate
...... timingPeriodPeriod
..... value[x] SI0..1Data to be provided
...... valueBooleanboolean
...... valueStringstring
...... valueQuantityQuantity
...... valueAttachmentAttachment
...... valueReferenceReference(Resource)
..... reason I0..1CodingExplanation for the information
Binding: MissingToothReasonCodes (example)
.... supportingInfo:discharge-status SI0..1BackboneElementDischarge Status
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence I1..1positiveIntInformation instance identifier
..... category I1..1CodeableConceptClassification of the supplied information
Binding: ClaimInformationCategoryCodes (example)
Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/ClaimInformationCategoryCS
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: discharge-status
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... code SI0..1CodeableConceptType of information
Binding: NUBC Patient Discharge Status (required)
..... timing[x] SI0..1When it occurred
...... timingDatedate
...... timingPeriodPeriod
..... value[x] SI0..1Data to be provided
...... valueBooleanboolean
...... valueStringstring
...... valueQuantityQuantity
...... valueAttachmentAttachment
...... valueReferenceReference(Resource)
..... reason I0..1CodingExplanation for the information
Binding: MissingToothReasonCodes (example)
.... supportingInfo:drg SI0..1BackboneElementClaim diagnosis related group (DRG)
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence I1..1positiveIntInformation instance identifier
..... category I1..1CodeableConceptClassification of the supplied information
Binding: ClaimInformationCategoryCodes (example)
Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/ClaimInformationCategoryCS
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: drg
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... code SI0..1CodeableConceptType of information
Binding: CMS-DRG (required)
..... timing[x] SI0..1When it occurred
...... timingDatedate
...... timingPeriodPeriod
..... value[x] SI0..1Data to be provided
...... valueBooleanboolean
...... valueStringstring
...... valueQuantityQuantity
...... valueAttachmentAttachment
...... valueReferenceReference(Resource)
..... reason I0..1CodingExplanation for the information
Binding: MissingToothReasonCodes (example)
.... supportingInfo:onadmissiontype SI0..1BackboneElementOn Admission Type
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence I1..1positiveIntInformation instance identifier
..... category I1..1CodeableConceptClassification of the supplied information
Binding: ClaimInformationCategoryCodes (example)
..... code SI0..1CodeableConceptType of information
Binding: Payer Diagnosis Present On Admission Diagnosis Type (required)
..... timing[x] SI0..1When it occurred
...... timingDatedate
...... timingPeriodPeriod
..... value[x] SI0..1Data to be provided
...... valueBooleanboolean
...... valueStringstring
...... valueQuantityQuantity
...... valueAttachmentAttachment
...... valueReferenceReference(Resource)
..... reason I0..1CodingExplanation for the information
Binding: MissingToothReasonCodes (example)
... diagnosis SI1..*BackboneElementThis is the reason given by the patient for visiting the doctor or practitioner. It is not the doctor's or practitioner's diagnosis. Patient Reason for Visit Codes can be any ICD-10diagnosis and may or may not be a repeat of an ICD-10 Principal or Secondary diagnosis field. (31 )
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence I1..1positiveIntDiagnosis instance identifier
.... diagnosis[x] SI1..1CodeableConceptA plain text representation of the diagnosis (145 )
Binding: ICD-10-CM Diagnosis Codes (required)
.... type SI1..1CodeableConceptTiming or nature of the diagnosis
Binding: Diagnosis Type -- Inpatient Facility (required)
.... onAdmission SI0..1CodeableConceptUsed to capture whether a diagnosis was present at time of a patient's admission. This is used to group diagnoses into the proper DRG for all claims involving inpatient admissions to general acute care facilities. (28 )
Binding: NUBC Present On Admission (required)
.... packageCode I0..1CodeableConceptPackage billing code
Binding: ExampleDiagnosisRelatedGroupCodes (example)
... procedure SI0..*BackboneElementPrincipal medical procedure a patient received during inpatient stay. Coding methods for this field is International Classification of Diseases Surgical Procedures (ICD-10). (24 )
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence I1..1positiveIntProcedure instance identifier
.... type SI0..*CodeableConceptCategory of Procedure
Binding: ExampleProcedureTypeCodes (example)
.... date SI0..1dateTimeWhen the procedure was performed
.... procedure[x] SI1..1(Slice Definition)Specific clinical procedure
Slice: Unordered, Closed by type:$this
Binding: ICD-10ProcedureCodes (example)
..... procedure[x]:procedureCodeableConcept I0..1CodeableConceptSpecific clinical procedure
Binding: ICD-10-PCS (required)
.... udi I0..*Reference(Device)Unique device identifier
... precedence I0..1positiveIntPrecedence (primary, secondary, etc.)
... insurance SΣI1..*BackboneElementIdentifies the primary payer. For use only on secondary claims. (141 )
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... focal SΣI1..1booleanCoverage to be used for adjudication
.... coverage SΣI1..1Reference(CARIN BB Coverage)Unique identifier for a member assigned by the Payer. If members receive ID cards, that is the identifier that should be provided. (1 )
.... preAuthRef I0..*stringPrior authorization reference number
... accident I0..1BackboneElementDetails of the event
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... date I0..1dateWhen the incident occurred
.... type I0..1CodeableConceptThe nature of the accident
Binding: ActIncidentCode (extensible)
.... location[x] I0..1Where the event occurred
..... locationAddressAddress
..... locationReferenceReference(Location)
... item SI0..*BackboneElementProduct or service provided
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence SI1..1positiveIntLine identification number that represents the number assigned in a source system for identification and processing. (36 )
.... careTeamSequence I0..*positiveIntApplicable care team members
.... diagnosisSequence I0..*positiveIntApplicable diagnoses
.... procedureSequence I0..*positiveIntApplicable procedures
.... informationSequence I0..*positiveIntApplicable exception and supporting information
.... revenue SI0..1CodeableConceptCode used on the UB-04 (Form Locator 42) to identify a specific accommodation, ancillary service, or billing calculation related to the service being billed (86 )
Binding: nubc-service-line-revenue (required)
.... category I0..1CodeableConceptBenefit classification
Binding: BenefitCategoryCodes (example)
.... productOrService SI1..1CodeableConceptMedical procedure a patient received from a health care provider. Current coding methods include: CPT-4 and HCFA Common Procedure Coding System Level II - (HCPCSII). (40 )
Binding: AMA CPT and CMS HCPCS Procedure Codes (required)
.... modifier SI0..*CodeableConceptModifier(s) for the procedure represented on this line. Identifies special circumstances related to the performance of the service. (41 )
Binding: AMA CPT and CMS HCPCS Modifier Codes (required)
.... programCode I0..*CodeableConceptProgram the product or service is provided under
Binding: ExampleProgramReasonCodes (example)
.... serviced[x] I0..1Date or dates of service or product delivery
..... servicedDatedate
..... servicedPeriodPeriod
.... location[x] I0..1Place of service or where product was supplied
Binding: ExampleServicePlaceCodes (example)
..... locationCodeableConceptCodeableConcept
..... locationAddressAddress
..... locationReferenceReference(Location)
.... quantity SI0..1SimpleQuantityThe quantity of units, times, days, visits, services, or treatments for the service described by the HCPCS code, revenue code or procedure code, submitted by the provider. (42 )
.... unitPrice I0..1MoneyFee, charge or cost per item
.... factor I0..1decimalPrice scaling factor
.... net I0..1MoneyTotal item cost
.... udi I0..*Reference(Device)Unique device identifier
.... bodySite I0..1CodeableConceptAnatomical location
Binding: OralSiteCodes (example)
.... subSite I0..*CodeableConceptAnatomical sub-location
Binding: SurfaceCodes (example)
.... encounter I0..*Reference(Encounter)Encounters related to this billed item
.... noteNumber I0..*positiveIntApplicable note numbers
.... adjudication SI0..*(Slice Definition)The quantity of units, times, days, visits, services, or treatments allowed for the service described by the HCPCS code, revenue code or procedure code, submitted by the provider. (149 )
Slice: Unordered, Closed by pattern:$this
..... adjudication:All Slices Content/Rules for all slices
...... id 0..1stringUnique id for inter-element referencing
...... extension I0..*ExtensionAdditional content defined by implementations
...... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... category SI1..1CodeableConceptType of adjudication information
Binding: Claim Adjudication Category (required)
...... reason I0..1CodeableConceptExplanation of adjudication outcome
Binding: AdjudicationReasonCodes (example)
...... amount I0..1MoneyMonetary amount
...... value I0..1decimalNon-monitary value
..... adjudication:adjudicationamounttype SI0..*BackboneElementAmounts
...... id 0..1stringUnique id for inter-element referencing
...... extension I0..*ExtensionAdditional content defined by implementations
...... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... category SI1..1CodeableConceptType of adjudication information
Binding: Adjudication CARINBB Value Codes (required)
...... reason I0..1CodeableConceptExplanation of adjudication outcome
Binding: AdjudicationReasonCodes (example)
...... amount SI0..1MoneyMonetary amount
...... value I0..1decimalNon-monitary value
..... adjudication:denialreason SI0..1BackboneElementDenial Reason
...... id 0..1stringUnique id for inter-element referencing
...... extension I0..*ExtensionAdditional content defined by implementations
...... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... category SI1..1CodeableConceptType of adjudication information
Binding: Claim Adjudication Category (required)
Required Pattern: At least the following
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
........ id0..1stringUnique id for inter-element referencing
........ extension0..*ExtensionAdditional content defined by implementations
........ system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/ClaimAdjudicationCategoryCS
........ version0..1stringVersion of the system - if relevant
........ code1..1codeSymbol in syntax defined by the system
Fixed Value: denialreason
........ display0..1stringRepresentation defined by the system
........ userSelected0..1booleanIf this coding was chosen directly by the user
....... text0..1stringPlain text representation of the concept
...... reason I1..1CodeableConceptExplanation of adjudication outcome
Binding: Adjudication Denial Reason (required)
...... amount I0..1MoneyMonetary amount
...... value I0..1decimalNon-monitary value
..... adjudication:allowedunits SI0..1BackboneElementAllowed number of units
...... id 0..1stringUnique id for inter-element referencing
...... extension I0..*ExtensionAdditional content defined by implementations
...... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... category SI1..1CodeableConceptType of adjudication information
Binding: Claim Adjudication Category (required)
Required Pattern: At least the following
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
........ id0..1stringUnique id for inter-element referencing
........ extension0..*ExtensionAdditional content defined by implementations
........ system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/ClaimAdjudicationCategoryCS
........ version0..1stringVersion of the system - if relevant
........ code1..1codeSymbol in syntax defined by the system
Fixed Value: allowedunits
........ display0..1stringRepresentation defined by the system
........ userSelected0..1booleanIf this coding was chosen directly by the user
....... text0..1stringPlain text representation of the concept
...... reason I0..1CodeableConceptExplanation of adjudication outcome
Binding: AdjudicationReasonCodes (example)
...... amount I0..1MoneyMonetary amount
...... value I0..1decimalNon-monitary value
.... detail I0..*BackboneElementAdditional items
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence I1..1positiveIntProduct or service provided
..... revenue I0..1CodeableConceptRevenue or cost center code
Binding: ExampleRevenueCenterCodes (example)
..... category I0..1CodeableConceptBenefit classification
Binding: BenefitCategoryCodes (example)
..... productOrService I1..1CodeableConceptBilling, service, product, or drug code
Binding: USCLSCodes (example)
..... modifier I0..*CodeableConceptService/Product billing modifiers
Binding: ModifierTypeCodes (example)
..... programCode I0..*CodeableConceptProgram the product or service is provided under
Binding: ExampleProgramReasonCodes (example)
..... quantity I0..1SimpleQuantityCount of products or services
..... unitPrice I0..1MoneyFee, charge or cost per item
..... factor I0..1decimalPrice scaling factor
..... net I0..1MoneyTotal item cost
..... udi I0..*Reference(Device)Unique device identifier
..... noteNumber I0..*positiveIntApplicable note numbers
..... adjudication I0..*See adjudicationDetail level adjudication details
..... subDetail I0..*BackboneElementAdditional items
...... id 0..1stringUnique id for inter-element referencing
...... extension I0..*ExtensionAdditional content defined by implementations
...... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... sequence I1..1positiveIntProduct or service provided
...... revenue I0..1CodeableConceptRevenue or cost center code
Binding: ExampleRevenueCenterCodes (example)
...... category I0..1CodeableConceptBenefit classification
Binding: BenefitCategoryCodes (example)
...... productOrService I1..1CodeableConceptBilling, service, product, or drug code
Binding: USCLSCodes (example)
...... modifier I0..*CodeableConceptService/Product billing modifiers
Binding: ModifierTypeCodes (example)
...... programCode I0..*CodeableConceptProgram the product or service is provided under
Binding: ExampleProgramReasonCodes (example)
...... quantity I0..1SimpleQuantityCount of products or services
...... unitPrice I0..1MoneyFee, charge or cost per item
...... factor I0..1decimalPrice scaling factor
...... net I0..1MoneyTotal item cost
...... udi I0..*Reference(Device)Unique device identifier
...... noteNumber I0..*positiveIntApplicable note numbers
...... adjudication I0..*See adjudicationSubdetail level adjudication details
... addItem I0..*BackboneElementInsurer added line items
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... itemSequence I0..*positiveIntItem sequence number
.... detailSequence I0..*positiveIntDetail sequence number
.... subDetailSequence I0..*positiveIntSubdetail sequence number
.... provider I0..*Reference(Practitioner | PractitionerRole | Organization)Authorized providers
.... productOrService I1..1CodeableConceptBilling, service, product, or drug code
Binding: USCLSCodes (example)
.... modifier I0..*CodeableConceptService/Product billing modifiers
Binding: ModifierTypeCodes (example)
.... programCode I0..*CodeableConceptProgram the product or service is provided under
Binding: ExampleProgramReasonCodes (example)
.... serviced[x] I0..1Date or dates of service or product delivery
..... servicedDatedate
..... servicedPeriodPeriod
.... location[x] I0..1Place of service or where product was supplied
Binding: ExampleServicePlaceCodes (example)
..... locationCodeableConceptCodeableConcept
..... locationAddressAddress
..... locationReferenceReference(Location)
.... quantity I0..1SimpleQuantityCount of products or services
.... unitPrice I0..1MoneyFee, charge or cost per item
.... factor I0..1decimalPrice scaling factor
.... net I0..1MoneyTotal item cost
.... bodySite I0..1CodeableConceptAnatomical location
Binding: OralSiteCodes (example)
.... subSite I0..*CodeableConceptAnatomical sub-location
Binding: SurfaceCodes (example)
.... noteNumber I0..*positiveIntApplicable note numbers
.... adjudication I0..*See adjudicationAdded items adjudication
.... detail I0..*BackboneElementInsurer added line items
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... productOrService I1..1CodeableConceptBilling, service, product, or drug code
Binding: USCLSCodes (example)
..... modifier I0..*CodeableConceptService/Product billing modifiers
Binding: ModifierTypeCodes (example)
..... quantity I0..1SimpleQuantityCount of products or services
..... unitPrice I0..1MoneyFee, charge or cost per item
..... factor I0..1decimalPrice scaling factor
..... net I0..1MoneyTotal item cost
..... noteNumber I0..*positiveIntApplicable note numbers
..... adjudication I0..*See adjudicationAdded items adjudication
..... subDetail I0..*BackboneElementInsurer added line items
...... id 0..1stringUnique id for inter-element referencing
...... extension I0..*ExtensionAdditional content defined by implementations
...... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... productOrService I1..1CodeableConceptBilling, service, product, or drug code
Binding: USCLSCodes (example)
...... modifier I0..*CodeableConceptService/Product billing modifiers
Binding: ModifierTypeCodes (example)
...... quantity I0..1SimpleQuantityCount of products or services
...... unitPrice I0..1MoneyFee, charge or cost per item
...... factor I0..1decimalPrice scaling factor
...... net I0..1MoneyTotal item cost
...... noteNumber I0..*positiveIntApplicable note numbers
...... adjudication I0..*See adjudicationAdded items adjudication
... adjudication SI0..*(Slice Definition)Header-level adjudication
Slice: Unordered, Closed by value:category
.... adjudication:All Slices Content/Rules for all slices
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category SI1..1CodeableConceptIndicates the in network or out of network payment status of the claim. (142 )
Binding: Claim Adjudication Category (required)
..... reason I0..1CodeableConceptExplanation of adjudication outcome
Binding: AdjudicationReasonCodes (example)
..... amount I0..1MoneyMonetary amount
..... value I0..1decimalNon-monitary value
.... adjudication:adjudicationamounttype SI0..*BackboneElementAmounts
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category I1..1CodeableConceptType of adjudication information
Binding: Adjudication CARINBB Value Codes (required)
..... reason I0..1CodeableConceptExplanation of adjudication outcome
Binding: AdjudicationReasonCodes (example)
..... amount I1..1MoneyMonetary amount
..... value I0..1decimalNon-monitary value
.... adjudication:denialreason SI0..1BackboneElementDenial Reason
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category I1..1CodeableConceptType of adjudication information
Binding: Claim Adjudication Category (required)
Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/ClaimAdjudicationCategoryCS
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: denialreason
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... reason I1..1CodeableConceptExplanation of adjudication outcome
Binding: Adjudication Denial Reason (required)
..... amount I0..1MoneyMonetary amount
..... value I0..1decimalNon-monitary value
... total ΣI1..*(Slice Definition)Adjudication totals
Slice: Unordered, Open by value:category
.... total:All Slices Content/Rules for all slices
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category SΣI1..1CodeableConceptType of adjudication information
Binding: Claim Adjudication Category (required)
..... amount SΣI1..1MoneyTotal amount for each category (i.e., submitted, allowed, etc.) (148 )
.... total:adjudicationamounttype SΣI0..*BackboneElementAmounts
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category ΣI1..1CodeableConceptType of adjudication information
Binding: Adjudication CARINBB Value Codes (required)
..... amount SΣI1..1MoneyFinancial total for the category
.... total:inoutnetwork SΣI1..1BackboneElementBenefit Payment Status
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category ΣI1..1CodeableConceptType of adjudication information
Binding: Benefit Payment Status (required)
..... amount SΣI1..1MoneyFinancial total for the category
... payment SI0..1BackboneElementPayment Details
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... type SI0..1CodeableConceptIndicates whether the claim was paid or denied. (91 )
Binding: Claim Payment Status Code (required)
.... adjustment I0..1MoneyPayment adjustment for non-claim issues
.... adjustmentReason SI0..1CodeableConceptReason codes used to interpret the Non-Covered Amount (92 )
Binding: PaymentAdjustmentReasonCodes (example)
.... date SI0..1dateThe date the claim was paid. (107 )
.... amount I0..1MoneyPayable amount after adjustment
.... identifier I0..1IdentifierBusiness identifier for the payment
... formCode I0..1CodeableConceptPrinted form identifier
Binding: Form Codes (example)
... form I0..1AttachmentPrinted reference or actual form
... processNote I0..*BackboneElementNote concerning adjudication
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... number I0..1positiveIntNote instance identifier
.... type I0..1codedisplay | print | printoper
Binding: NoteType (required)
.... text I0..1stringNote explanatory text
.... language I0..1CodeableConceptLanguage of the text
Binding: CommonLanguages (preferred)
Max Binding: AllLanguages
... benefitPeriod I0..1PeriodWhen the benefits are applicable
... benefitBalance I0..*BackboneElementBalance by Benefit Category
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... category I1..1CodeableConceptBenefit classification
Binding: BenefitCategoryCodes (example)
.... excluded I0..1booleanExcluded from the plan
.... name I0..1stringShort name for the benefit
.... description I0..1stringDescription of the benefit or services covered
.... network I0..1CodeableConceptIn or out of network
Binding: NetworkTypeCodes (example)
.... unit I0..1CodeableConceptIndividual or family
Binding: UnitTypeCodes (example)
.... term I0..1CodeableConceptAnnual or lifetime
Binding: BenefitTermCodes (example)
.... financial I0..*BackboneElementBenefit Summary
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... type I1..1CodeableConceptBenefit classification
Binding: BenefitTypeCodes (example)
..... allowed[x] I0..1Benefits allowed
...... allowedUnsignedIntunsignedInt
...... allowedStringstring
...... allowedMoneyMoney
..... used[x] I0..1Benefits used
...... usedUnsignedIntunsignedInt
...... usedMoneyMoney

doco Documentation for this format

 

Other representations of profile: Schematron

Terminology Bindings

PathConformanceValueSet / Code
ExplanationOfBenefit.meta.securityextensibleAll Security Labels
ExplanationOfBenefit.meta.tagexampleCommonTags
ExplanationOfBenefit.languagepreferredCommonLanguages
Max Binding: AllLanguages
ExplanationOfBenefit.identifier:claimnumber.userequiredIdentifierUse
ExplanationOfBenefit.identifier:claimnumber.typeextensibleIdentifier Type Codes
ExplanationOfBenefit.statusrequiredExplanationOfBenefitStatus
ExplanationOfBenefit.typerequiredPattern: institutional
ExplanationOfBenefit.subTypeexampleExampleClaimSubTypeCodes
ExplanationOfBenefit.userequiredPattern: claim
ExplanationOfBenefit.priorityexamplehttp://terminology.hl7.org/CodeSystem/processpriority
ExplanationOfBenefit.fundsReserveRequestedexampleFunds Reservation Codes
ExplanationOfBenefit.fundsReserveexampleFunds Reservation Codes
ExplanationOfBenefit.related.relationshipexampleExampleRelatedClaimRelationshipCodes
ExplanationOfBenefit.payee.typeexampleClaim Payee Type Codes
ExplanationOfBenefit.outcomerequiredClaimProcessingCodes
ExplanationOfBenefit.careTeam.rolerequiredCARINBBInstitutionalClaimCareTeamRoleCodes
ExplanationOfBenefit.careTeam.qualificationexampleExampleProviderQualificationCodes
ExplanationOfBenefit.supportingInfo.categoryexampleClaimInformationCategoryCodes
ExplanationOfBenefit.supportingInfo.codeexampleExceptionCodes
ExplanationOfBenefit.supportingInfo.reasonexampleMissingToothReasonCodes
ExplanationOfBenefit.supportingInfo:billingnetworkcontractingstatus.categoryexamplePattern: billingnetworkcontractingstatus
ExplanationOfBenefit.supportingInfo:billingnetworkcontractingstatus.coderequiredPayerProviderContractingStatus
ExplanationOfBenefit.supportingInfo:billingnetworkcontractingstatus.reasonexampleMissingToothReasonCodes
ExplanationOfBenefit.supportingInfo:attendingnetworkcontractingstatus.categoryexamplePattern: attendingnetworkcontractingstatus
ExplanationOfBenefit.supportingInfo:attendingnetworkcontractingstatus.coderequiredPayerProviderContractingStatus
ExplanationOfBenefit.supportingInfo:attendingnetworkcontractingstatus.reasonexampleMissingToothReasonCodes
ExplanationOfBenefit.supportingInfo:referringnetworkcontractingstatus.categoryexamplePattern: referringnetworkcontractingstatus
ExplanationOfBenefit.supportingInfo:referringnetworkcontractingstatus.coderequiredPayerProviderContractingStatus
ExplanationOfBenefit.supportingInfo:referringnetworkcontractingstatus.reasonexampleMissingToothReasonCodes
ExplanationOfBenefit.supportingInfo:supervisingnetworkcontractingstatus.categoryexamplePattern: supervisingnetworkcontractingstatus
ExplanationOfBenefit.supportingInfo:supervisingnetworkcontractingstatus.coderequiredPayerProviderContractingStatus
ExplanationOfBenefit.supportingInfo:supervisingnetworkcontractingstatus.reasonexampleMissingToothReasonCodes
ExplanationOfBenefit.supportingInfo:clmrecvddate.categoryexamplePattern: clmrecvddate
ExplanationOfBenefit.supportingInfo:clmrecvddate.codeexampleExceptionCodes
ExplanationOfBenefit.supportingInfo:clmrecvddate.reasonexampleMissingToothReasonCodes
ExplanationOfBenefit.supportingInfo:typeofbill.categoryexamplePattern: typeofbill
ExplanationOfBenefit.supportingInfo:typeofbill.coderequiredhttp://hl7.org/fhir/ValueSet/nubc-type-of-bill
ExplanationOfBenefit.supportingInfo:typeofbill.reasonexampleMissingToothReasonCodes
ExplanationOfBenefit.supportingInfo:pointoforigin.categoryexamplePattern: admsrc
ExplanationOfBenefit.supportingInfo:pointoforigin.coderequiredhttp://hl7.org/fhir/ValueSet/nubc-admission-source
ExplanationOfBenefit.supportingInfo:pointoforigin.reasonexampleMissingToothReasonCodes
ExplanationOfBenefit.supportingInfo:admtype.categoryexamplePattern: admtype
ExplanationOfBenefit.supportingInfo:admtype.coderequiredNUBCPriorityOfAdmissionn
ExplanationOfBenefit.supportingInfo:admtype.reasonexampleMissingToothReasonCodes
ExplanationOfBenefit.supportingInfo:discharge-status.categoryexamplePattern: discharge-status
ExplanationOfBenefit.supportingInfo:discharge-status.coderequiredNUBCPatientDischargeStatus
ExplanationOfBenefit.supportingInfo:discharge-status.reasonexampleMissingToothReasonCodes
ExplanationOfBenefit.supportingInfo:drg.categoryexamplePattern: drg
ExplanationOfBenefit.supportingInfo:drg.coderequiredCMSDRG
ExplanationOfBenefit.supportingInfo:drg.reasonexampleMissingToothReasonCodes
ExplanationOfBenefit.supportingInfo:onadmissiontype.categoryexampleClaimInformationCategoryCodes
ExplanationOfBenefit.supportingInfo:onadmissiontype.coderequiredPayerDiagnosisPresentOnAdmissionDiagnosisType
ExplanationOfBenefit.supportingInfo:onadmissiontype.reasonexampleMissingToothReasonCodes
ExplanationOfBenefit.diagnosis.diagnosis[x]requiredICD10CM
ExplanationOfBenefit.diagnosis.typerequiredPayerInpatientfacilitydiagnosistype
ExplanationOfBenefit.diagnosis.onAdmissionrequiredNUBCPresentOnAdmission
ExplanationOfBenefit.diagnosis.packageCodeexampleExampleDiagnosisRelatedGroupCodes
ExplanationOfBenefit.procedure.typeexampleExampleProcedureTypeCodes
ExplanationOfBenefit.procedure.procedure[x]exampleICD-10ProcedureCodes
ExplanationOfBenefit.procedure.procedure[x]:procedureCodeableConceptrequiredICD10PCS
ExplanationOfBenefit.accident.typeextensibleActIncidentCode
ExplanationOfBenefit.item.revenuerequiredhttp://hl7.org/fhir/ValueSet/nubc-service-line-revenue
ExplanationOfBenefit.item.categoryexampleBenefitCategoryCodes
ExplanationOfBenefit.item.productOrServicerequiredAMACPTCMSHCPCSProcedureCodes
ExplanationOfBenefit.item.modifierrequiredAMACPTCMSHCPCSProcedureModifiers
ExplanationOfBenefit.item.programCodeexampleExampleProgramReasonCodes
ExplanationOfBenefit.item.location[x]exampleExampleServicePlaceCodes
ExplanationOfBenefit.item.bodySiteexampleOralSiteCodes
ExplanationOfBenefit.item.subSiteexampleSurfaceCodes
ExplanationOfBenefit.item.adjudication.categoryrequiredClaimAdjudicationCategory
ExplanationOfBenefit.item.adjudication.reasonexampleAdjudicationReasonCodes
ExplanationOfBenefit.item.adjudication:adjudicationamounttype.categoryrequiredAdjudicationCarinBBValueCodes
ExplanationOfBenefit.item.adjudication:adjudicationamounttype.reasonexampleAdjudicationReasonCodes
ExplanationOfBenefit.item.adjudication:denialreason.categoryrequiredPattern: denialreason
ExplanationOfBenefit.item.adjudication:denialreason.reasonrequiredAdjudicationDenialReason
ExplanationOfBenefit.item.adjudication:allowedunits.categoryrequiredPattern: allowedunits
ExplanationOfBenefit.item.adjudication:allowedunits.reasonexampleAdjudicationReasonCodes
ExplanationOfBenefit.item.detail.revenueexampleExampleRevenueCenterCodes
ExplanationOfBenefit.item.detail.categoryexampleBenefitCategoryCodes
ExplanationOfBenefit.item.detail.productOrServiceexampleUSCLSCodes
ExplanationOfBenefit.item.detail.modifierexampleModifierTypeCodes
ExplanationOfBenefit.item.detail.programCodeexampleExampleProgramReasonCodes
ExplanationOfBenefit.item.detail.subDetail.revenueexampleExampleRevenueCenterCodes
ExplanationOfBenefit.item.detail.subDetail.categoryexampleBenefitCategoryCodes
ExplanationOfBenefit.item.detail.subDetail.productOrServiceexampleUSCLSCodes
ExplanationOfBenefit.item.detail.subDetail.modifierexampleModifierTypeCodes
ExplanationOfBenefit.item.detail.subDetail.programCodeexampleExampleProgramReasonCodes
ExplanationOfBenefit.addItem.productOrServiceexampleUSCLSCodes
ExplanationOfBenefit.addItem.modifierexampleModifierTypeCodes
ExplanationOfBenefit.addItem.programCodeexampleExampleProgramReasonCodes
ExplanationOfBenefit.addItem.location[x]exampleExampleServicePlaceCodes
ExplanationOfBenefit.addItem.bodySiteexampleOralSiteCodes
ExplanationOfBenefit.addItem.subSiteexampleSurfaceCodes
ExplanationOfBenefit.addItem.detail.productOrServiceexampleUSCLSCodes
ExplanationOfBenefit.addItem.detail.modifierexampleModifierTypeCodes
ExplanationOfBenefit.addItem.detail.subDetail.productOrServiceexampleUSCLSCodes
ExplanationOfBenefit.addItem.detail.subDetail.modifierexampleModifierTypeCodes
ExplanationOfBenefit.adjudication.categoryrequiredClaimAdjudicationCategory
ExplanationOfBenefit.adjudication.reasonexampleAdjudicationReasonCodes
ExplanationOfBenefit.adjudication:adjudicationamounttype.categoryrequiredAdjudicationCarinBBValueCodes
ExplanationOfBenefit.adjudication:adjudicationamounttype.reasonexampleAdjudicationReasonCodes
ExplanationOfBenefit.adjudication:denialreason.categoryrequiredPattern: denialreason
ExplanationOfBenefit.adjudication:denialreason.reasonrequiredAdjudicationDenialReason
ExplanationOfBenefit.total.categoryrequiredClaimAdjudicationCategory
ExplanationOfBenefit.total:adjudicationamounttype.categoryrequiredAdjudicationCarinBBValueCodes
ExplanationOfBenefit.total:inoutnetwork.categoryrequiredBenefitPaymentStatus
ExplanationOfBenefit.payment.typerequiredClaimPaymentStatusCode
ExplanationOfBenefit.payment.adjustmentReasonexamplePaymentAdjustmentReasonCodes
ExplanationOfBenefit.formCodeexampleForm Codes
ExplanationOfBenefit.processNote.typerequiredNoteType
ExplanationOfBenefit.processNote.languagepreferredCommonLanguages
Max Binding: AllLanguages
ExplanationOfBenefit.benefitBalance.categoryexampleBenefitCategoryCodes
ExplanationOfBenefit.benefitBalance.networkexampleNetworkTypeCodes
ExplanationOfBenefit.benefitBalance.unitexampleUnitTypeCodes
ExplanationOfBenefit.benefitBalance.termexampleBenefitTermCodes
ExplanationOfBenefit.benefitBalance.financial.typeexampleBenefitTypeCodes

Constraints

IdPathDetailsRequirements
EOB-inst-careTeam-practitionerExplanationOfBenefit.careTeamInstitutional EOB: Careteam roles refer to a practitioner
: ( careTeam.role.coding.code in ('attending' or 'pcp' or 'referring' or 'supervising')) implies careTeam.provider.reference.resolve().is(FHIR.Practitioner)
EOB-inst-careTeam-organizationExplanationOfBenefit.careTeamInstitutional EOB: Careteam roles refer to a practitioner
: ( careTeam.role.coding.code='performing') implies careTeam.provider.reference.resolve().is(FHIR.Organization)